THE   TREATMENT    OF    INFECTED 

WOUNDS 


THE    TREATMENT    OF 
INFECTED    WOUNDS 


BY 

A.  CARREL  AND   G.   DEHELLY 


TRANSLATION   BY 

HERBERT   CHILD 

FORMERLY   SURGEON     FRENCH   RED    CROSS,   CAPT.    R.A.M.C.  (tY.) 


WITH   INTRODUCTION   BY 

SIR   ANTHONY   A.   BOWLBY 

K.C.M.G.,    K.C.V.O.,    F.R.C.S.,    SURGEON-GENERAL,    ARMY   MEDICAL    SERVICE 
ADVISING  CONSULTING  SURGEON  TO  THE  BRITISH  ARMIES  IN  FRANCE 


NEW    YORK 
PAUL    B.    HOEBER 

67-69   EAST    59th    STREET 
1917 


PRINTED  IN   GREAT  BRITAIN 


o 

-J 


CD 


^  INTRODUCTION 

I  HAVE  been  asked  to  write  an  Introduction  to  the 
English  edition  of  the  work  by  Dr.  A.  Carrel  and  Dr.  G. 
Dehelly,  and  I  am  glad  to  take  the  opportunity  of  ex- 
pressing the  appreciation  of  British  surgeons  at  the 
Front  of  the  value  of  what  is  known  to  us  as  ''  Carrel's 
Method." 

Whenever  it  has  been  thoroughly  carried  out  it  has 
accomplished  all  that  is  claimed  for  it  by  its  author,  and 
it  has  been  of  inestimable  benefit  to  thousands  of  patients. 
It  has  also  renewed  faith  in  antiseptic  methods,  in  spite 
of  the  attacks  on  their  utility  which  characterised  the 
early  stages  of  the  war,  and  has  done  the  greatest  good 
by  setting  a  high  standard  of  thorough  excision  and 
surgical  cleanliness.  The  whole  practice  of  war  surgery 
has  been  greatly  improved  by  Dr.  Carrel's  confidence 
that  antiseptic  treatment  can  sterilise  a  septic  wound, 
and  that  it  does  do  so  if  sufficient  care  and  skill  are 
bestowed  upon  it ;  and  the  lesson  he  has  taught  was 
very  necessary. 

The  book  itself  will  be  found  to  convey  in  the 
clearest  manner  the  knowledge  of  those  details  which 
have  been  so  carefully  elaborated  by  the  patient  work 
of  two  years'  experience,  but  it  is  only  by  scrupulous 
attention  to  every  detail  that  the  best  results  will  be 
obtained. 


vi  INTRODUCTION 

I  would  also  suggest  that,  if  "  Carrel's  Method  "  is  to 
be  fairly  judged,  no  change  whatever  should  be  made 
either  in  the  Dakin's  solution  itself,  or  in  the  use  of 
the  tubes  for  instilling  it.  The  tendency  has  often  been 
so  to  modify  these  details,  in  the  belief  that  they  were 
thereby  "  improved,"  that  the  author  himself  would  be 
the  first  to  disclaim  the  improved  methods  which  are  yet 
called  by  his  name.  The  only  modification  that  seems 
justifiable  is  the  use  of  the  syringe  when  instillation  by 
gravitation  cannot  be  carried  out,  as  in  trains,  ships,  and 
many  units  at  the  Front.  It  will  be  time  enough  to 
introduce  other  modifications  after  a  prolonged  trial  of 
the  methods  advised  in  this  publication. 

The  utility  of  Carrel's  method  is  not  confined  to 
recent  wounds,  and,  in  the  following  pages,  those  surgeons 
who  are  treating  the  wounded  in  Great  Britain  will  find 
all  the  necessary  information  for  the  treatment  of  both 
healthy  and  suppurating  wounds. 

The  Army  Medical  Department  has  already  arranged 
that,  in  those  cases  where  it  is  employed,  this  treatment 
can  be  continuously  carried  out  not  only  in  the  Front 
and  Base  Hospitals,  but  also  in  Ambulance  Trains, 
Hospital  Ships,  and  Hospitals  in  Great  Britain. 

To  the  workers  in  each  of  these  areas  of  surgery  this 
book  will  prove  of  the  utmost  practical  value,  and  I  feel 
certain  it  will  be  of  the  greatest  value  of  all  to  the 
patients  themselves. 

ANTHONY   A.  BOWLBY. 

General  Headquarters, 

B.E.F.,  France, 

May,   191 7. 


PREFACE 

The  researches  which  are  dealt  with  In  this  book  were 
made  in  the  laboratories  established  at  Compiegne  by 
the  Rockefeller  Foundation,  and  at  the  Temporary 
Hospital,  No.  21,  under  the  Service  du  Sante  militaire. 

The  chemical  laboratory  was  directed  by  Dr.  Henry 
D.  Dakin,^  who  there  made  the  experiments  upon  which 
the  sterilisation  of  wounds  is  founded.  In  the  biological 
part  of  his  experiments.  Dr.  Dakin  was  assisted  by  M. 
Daufresne  and  Mme  Carrel.  Chemical  research  was 
carried  on  in  the  same  laboratory  by  M.  Daufresne. 
Le  medecin-major  Vincent,  of  the  colonial  forces,  directed 
the  bacteriological  laboratory.  The  mathematical  and 
physical  portion  of  the  researches  was  done  by  M. 
Lecomte  du  Nouy  and  M.  Jaubert  de  Beaujeu.  The 
physiological  and  surgical  experiments  were  made  with 
the  help  of  Miss  Lilly.  Photography  by  MM.  Pierre 
Magnier  and  Baillergeau. 

The  wounded  were  treated  successively  by  M.  Dumas, 
and  by  le  medecin-major  Bernoud  of  the  colonial  forces, 
then  by  MM.  Woimant,  Audiganne,  and  Guillot.  MM. 
Guillot  and  Woimant  dealt  with  the  surgical  experiments. 

*  Dr.  H.  D.  Dakin,  Director  of  the  Herter  Laboratory,  New  York, 
was  one  of  the  candidates  selected  by  the  Council  of  the  Royal  Society  to 
be  recommended  for  election  into  the  Society.  (B.  I^T.J,,  March  13,  I917. 
Translator  s  note.) 


viii  PREFACE 

Clinical  investigations  into  the  cicatrisation  of  wounds 
were  made  by  Mile  Hartmann  and  by  Mme  Carrel.  M. 
Jaubert  de  Beaujeu  was  in  charge  of  the  radiological 
laboratory. 

The  administration  of  the  hospital  and  the  laboratories 
was  in  the  hands  of  les  officiers  d'administration  Bierer 
and  Bois,  successively. 

The  nursing  was  done  by  the  infirmieres  of  I'Ecole 
de  la  Source,  superintended  by  Mme  Carrel,  by  Mile 
Weilenmann  and  Mile  Junod,  and  by  the  American 
nurses  of  the  "  Post  Unit." 

The  military  administration  of  the  hospital  was 
directed  by  mcdecin-major  Bernoud,  of  the  colonial 
forces. 

The  hospital  was  controlled  by  M.  le  Sous-Secretaire 
d'P2tat  du  Service  de  Sante,  and  all  the  details  of  its 
organisation  and  administration  were  in  charge  of  M.  de 
Piessac,  of  the  Sous-Secretariat  d'Etat. 

A.    CARREL. 

CoMl'liiGNE. 


CONTENTS 

CHAP.  PAGE 

Introduction  by  vSir  Anthony  A.  Bowlby        .         .        .  v 

Preface vii 

Introduction i 

I.     The  Principles  of  the  Technique 13 

II.     Technique  of  the  Manufacture  of  Dakin's  Solution       .  73 

III.  The   Technique   of    the    Sterilisation    of   Wounds — 

Mechanical,  Chemical,  and  Surgical  Cleansing         .  89 

IV.  The    Technique    of   the    Sterilisation   of  Wounds- 

Chemical  Sterilisation         .         .         .         .         .         .112 

V.     Clinical  and  Bacteriological  Examination  of  Wounds  .  147 

VI.    The  Closure  of  Wounds 17S 

VII.     The  Results 188 

Appendix. — Chloramine  Paste 228 

Index 229 


THE  TREATMENT 
OF   INFECTED   WOUNDS 

INTRODUCTION 

I.  It  is  well  known  that  nearly  all  the  wounds  resulting 
from  explosions  of  shells,  torpedoes,  bombs,  are  septic  ; 
and  that  the  methods  employed  up  to  the  present  in 
the  treatment  of  these  wounds  are  generally  impotent 
to  check  the  progress  of  the  infection.  To  be  convinced 
of  this,  one  has  only  to  be  present  at  the  arrival  at  a 
base  hospital  of  a  convoy  of  wounded,  who  have  been 
operated  on  in  the  dressing-stations  or  the  hospitals 
near  the  front.  Then  one  grasps  the  danger  of  those 
paradoxes  upheld  by  surgeons  who  still  deny  the  uni- 
versality of  infection. 

That  the  septic  character  of  wounds  is  disastrous  is 
also  well  known.  During  the  early  hours,  or  the  first  few 
days,  the  wound  is  exposed  to  the  danger  of  gas-producing 
infection.  Later  are  developed  the  various  infections, 
which,  either  in  the  seat  of  fracture,  joints  laid  open,  or 
in  extensive  lacerations  of  soft  parts,  sometimes  give  rise 
to  lesions  leading  to  amputation  or  to  death.  At  the 
hospital  of  the  Maison  Blanche,  M.  Tuffier,  as  a  result  of 
the  examination  of  a  large  number  of  cases  of  amputa- 
tion, found  that  about   70  per  cent,   of  the  operations 

I  I 


2     TREATMENT   OF    INFECTED   WOUNDS 

were  needed  because  of  the  presence  of  infection,  and 
were  not  due  to  the  extent  of  the  anatomical  lesions. 

Even  when  the  patient  has  had  the  good  fortune  to  be 
operated  on  close  to  the  scene  of  action  by  a  competent 
surgeon,  and  has  escaped  the  serious  infections  of  the 
early  stages,  suppuration  still  occurs,  continues  indefinitely. 
Sometimes  it  becomes  a  danger  to  life  or  limb,  and  almost 
always  brings  about  adhesions  between  muscles,  aponeu- 
roses, tendons,  nerves  and  vessels.  After  healing,  the 
patient  has  scars  of  large  area,  often  painful,  which 
prevent  the  limb  from  resuming  its  normal  functions. 
Tendons  stay  gripped  in  fibrous  fetters.  Nerve  ex- 
tremities which  have  been  bathed  for  weeks  in  pus, 
sclerose.  Deep  in  infected  bones,  osteo-myelitis  springs 
up.  For  months,  maybe  years,  the  limb  still  suppurates. 
Joints  ankylose,  muscles  atrophy,  and  the  wounded  man 
becomes  unfit,  not  only  for  being  a  soldier,  but  for  work 
of  any  kind. 

The  suppression  of  wound  infection  would  protect  a 
large  number  of  men  from  incapacity  or  death,  and  would 
bring  about  the  rapid  restoration  to  health  of  the  greater 
number  of  those  whose  anatomical  lesions  are  compatible 
with  life.  Such  progress  would  result  in  great  saving  in 
money  and  men. 

It  would  seem,  however,  that  hitherto  practically  no 
really  systematic  research  has  been  carried  out  with  the 
object  of  discovering  the  procedure  needful  to  bring  about 
this  improvement  in  treatment  of  wounded.  As  a  matter 
of  fact,  attempts  have  been  made  by  isolated  individuals 
and  often  with  extemporised  equipment.  Experi- 
menters have  attempted,  working  alone,  researches  which 
needed  the  co-ordinated  efforts  of  chemists,  pathologists. 


INTRODUCTION  3 

bacteriologists,  trained  in  scientific  technique.  Pro- 
ceedings of  learned  societies  are  laden  with  reports, 
based  for  the  greater  part  on  experiments  and  observa- 
tions, incomplete,  vitiated  by  faulty  methods.  No 
results  of  value  were  obtained.  Despite  the  academic 
toil  of  many  surgeons,  wounds  suppurate  to-day  as 
freely  as  ever. 

It  is  known,  however,  that,  under  certain  conditions, 
infected  wounds  can  be  rendered  sterile.  Lister,  un- 
doubtedly, by  the  aid  of  carbolic  acid,  succeeded  in  dis- 
infecting compound  fractures,  at  a  time  when  such  an 
injury  was  of  the  gravest  import.  Nevertheless,  modern 
surgeons  ch'sregard  these  facts.  Not  only  have  they 
despised  the  road  opened  up  by  Lister,  but  they  even 
question  the  possibility  of  applying  the  principle  of 
antiseptics  to  war  wounds. 

The  throwing-over  of  Lister's  ideas  came  about,  not 
so  much  from  the  inadequacy  of  his  method,  as  from  the 
carelessness  with  which  it  was  applied.  In  clinical  re- 
searches, the  basic  principles  of  scientific  investigation 
were  forgotten.  Methods  utilising  measurements  were 
rarely  employed.  In  the  wounds  investigated,  it  was 
never  sought  to  estimate  exactly  the  relations  which 
exist  between  the  number  of  microbes  present,  their 
nature,  and  the  rapidity  of  cicatrisation.  Any  substance 
which  possessed  the  property  of  destroying  microbes  in 
vitro,  was  looked  upon  as  an  antiseptic,  and  used  in  the 
treatment  of  wounds,  every  man  to  his  taste.  Substances 
which  coagulated  proteids,  which  lost  their  bactericidal 
power  in  the  presence  of  serum,  or  which  were  actually 
harmful  to  the  tissues,  were  all  used.  What  degree 
of  concentration    of    a    bactericidal    substance    was    to 


4     TREATMENT    OF    INFECTED    WOUNDS 

be  used  at  the  surface  of  a  wound,  how  this  degree  of 
concentration  was  to  be  maintained — such  details  were 
never  sought.  The  period  during  which  this  substance 
should  remain  on  the  surface  of  the  wound,  at  a  given 
concentration,  was  never  determined.  No  careful  study 
was  made  of  the  quantitative  modifications,  produced  by 
the  antiseptic  agent,  of  the  microbial  flora,  modifications 
which  can  only  be  revealed  by  daily  bacteriological  ex- 
amination. The  action  of  antiseptics  on  tissue  repair 
was  ignored,  although  it  was  important  to  learn  how 
much  the  substances  employed  would  impede  the 
progress  of  cicatrisation.  In  a  word,  in  the  therapeutics 
of  septic  wounds,  we  may  attribute  the  stagnation  we 
have  experienced  to  the  lack  of  precision  in  clinical 
research. 

However,  Lister's  method  was  held  responsible  for 
technical  inadequacies,  and  surgeons  raised  to  the  posi- 
tion of  dogma,  the  teaching  that  antiseptics  had  no 
real  efficacy.  In  a  memorandum  on  the  treatment  of 
wounds  in  war,^  MM.  Burghard,  Leishman,  Moynihan 
and  Wright,  wrote  in  April,  191 5,  that  "  the  treatment  of 
suppurating  wounds  by  means  of  antiseptics  is  illusory, 
and  that  belief  in  its  efficacy  is  founded  upon  false 
reasoning."  The  principal  adversary  of  antisepsis  was 
Sir  Almroth  Wright.  He  believed  that  Lister's  method 
was  not  applicable  to  war-wounds,  and  that  the  microbes, 
being  carried  by  projectiles  and  fragments  of  clothing 
deep  into  the  tissues,  were  beyond  the  reach  of  anti- 
septics. Chemical  sterilisation  of  a  wound  seemed  to 
him  impossible   of  realisation.     "  In  fact,"  he  wrote  in 

'  Burghard,   I.cibhman,  Moynihan   and  Wright,    Office  international 
<P hygiene publique^  19 15,  vol.  vii.  p.  946. 


INTRODUCTION  5 

191 5,  "if  it  were  ever  to  come  about  that  an  antiseptic 
sterilised  heavily  infected  wounds,  that  would  be  a  matter 
to  announce  in  all  the  evening  and  morning  papers."  ^ 

Although  Sir  Almroth  Wright's  doctrine  was  founded, 
not  on  observations  and  experiments  made  upon  wounds 
under  actual  war  conditions,  but  upon  ingenious  theories 
and  experiments  in  vitro^  it  was  accepted  by  the  majority 
of  surgeons.  One  of  them  even  affirms  that  asepsis 
ought  to  take  the  place  of  antisepsis,  and  that  anti- 
septics not  only  fail  to  sterilise  wounds,  but  that 
they  actually  favour  the  development  of  microbes !  ^ 
Therefore  wounds  came  to  be  treated  with  saline  solu- 
tions, or  the  hypertonic  solutions  of  Wright.  The 
fundamental  observations  of  Lister  were  forgotten  com- 
pletely. Nevertheless,  theories  remained  impotent  and 
infection  flourished. 

II.  However,  setting  aside  theory  and  confining 
oneself  closely  to  fact,  the  problem  of  wound  sterilisa- 
tion seems  very  simple.  It  is  to  be  remembered  that 
the  surgical  infection,  at  the  outset,  is  always  local.  In 
war- wounds,  it  is  carried  by  projectiles,  and  especially  by 
fragments  of  clothing,  impregnated  with  micro-organ- 
isms. Before  crossing  the  boundaries  of  the  wound,  these 
flourish  on  the  surface  of  the  tissues.  Therefore,  durine 
a  period  more  or  less  long,  the  infection  is  under  control, 
since  the  microbes  are,  so  to  speak,  within  reach  of  the 
hand.  The  question  then  is  simply,  how  to  destroy  them 
without  harming  the  tissues  1 

*  Sir  A.  Wright.  An  Address  on  Wound  Infections.  British  Medical 
Jojtrnal,  April  24,  1915,  p.  721. 

-  Pierre  Delbet,  Bulletin  et  Mimoires  de  la  Societe  de  Chirjo-gie^ 
Janvier,  1916. 


6     TREATMENT   OF   INFECTED   WOUNDS 

As  a  difference  of  resistance  exists  between,  on  one 
hand,  the  tissues  provided  with  a  circulation,  and,  on 
the  other  hand — microbes,  isolated  anatomical  elements 
and  necrosed  tissues,  it  was  useless  to  seek  a  substance 
which  would  exercise  an  elective  action  on  micro- 
organisms. Better  seek  to  discover,  for  a  given  antiseptic, 
that  degree  of  concentration  of  the  solution,  and  that  length 
of  time  during  which  it  must  be  applied,  which,  fatal  to 
microbes,  will  not  produce  obvious  damage  to  the  tissues. 

When,  at  the  end  of  December,  1914,  Henry  D. 
Dakin  and  one  of  the  authors  of  this  book  sought  to 
discover  the  best  means  of  treating  wound-infections, 
they  adopted,  for  the  reasons  just  stated,  the  method  of 
chemio-therapy.  Besides,  it  seemed  probable  that  the 
infection  of  war-inflicted  wounds  would  be  unsuitable 
for  treatment  by  vaccines  or  serums.  As  the  inocula- 
tion of  the  tissues  by  projectiles  or  fragments  of  cloth- 
ing is  massive,  and  as  the  germs  protected  by  necrosed 
tissues  or  blood-clots  multiply  beyond  the  reach  of 
lymph-flow,  it  is  extremely  unlikely  that  such  thera- 
peusis  could  be  effective.  Besides,  the  bacterial  flora  of 
war-wounds  is  extremely  varied.  As  the  large  numbers 
of  wounded  and  the  conditions  of  the  dressing-stations 
render  impossible  identification  of  the  microbes  which 
infect  the  wounds,  it  would  be  necessary  to  use  vaccines 
or  serums  against  dozens  of  types  of  germs,  aerobic  and 
anaerobic.     Failure  of  such  an  attempt  is  foredoomed. 

On  the  other  hand,  the  problem  would  appear  to  be 
readily  solved  by  using  a  substance  unirritating  to  the 
tissues,  and  of  a  sufficient  bactericidal  power  to  kill  all 
the  microbes  present  in  a  wound,  be  their  nature  what 
it  may. 


INTRODUCTION  7 

It  was  in  this  direction  that  the  researches  tended. 
Dakin  studied  the  action  on  tissues  and  micro-organisms 
of  a  considerable  number  of  antiseptics,  old  and  new. 
More  than  two  hundred  substances  were  examined  in 
this  manner  by  him,  and  he  was  led,  for  various  reasons, 
to  make  chloramines,^  and,  by  a  special  process,  hypo- 
chlorite of  soda.^  Thanks  to  his  excellent  researches, 
we  quickly  had  placed  at  our  disposal  substances 
endowed  with  feeble  irritating  qualities,  with  a  toxicity 
for  the  organism  almost  nil,  but  of  considerable  bac- 
tericidal power.  We  then  studied  under  what  con- 
ditions these  substances  could  sterilise  a  wound.  These 
researches  demonstrated  that  the  microbes  disappeared, 
if  the  antiseptic  remained  in  contact  with  the  surface  of 
the  wound  at  a  certain  degree  of  concentration  during  a 
prolonged  period.  Bacteriological  examination  showed 
that  infected  wounds,  treated  according  to  these  principles, 
became  sterile.  Thus,  quite  simply,  was  realised  what 
Sir  Almroth  Wright  and  modern  surgeons  consider  to 
be  impossible. 

III. — The  method  was  applied  in  the  first  place  to 
old  wounds,  afterwards  to  recent  ones.  Sterilisation 
was  attained  in  both  cases,  but  the  earlier  treatment  gave 
the  more  rapid  results.  It  has  long  been  admitted  that 
preventive  treatment  of  a  malady  costs  less  in  money  and 
toil  than  curative  treatment.  However,  infection  can  be 
checked  even  after  suppuration  has  become  established. 
In  a  word,  all  infected  wounds  were  brought  more  or 
less  under  control  by  chemio-therapy. 

^  Dakin,    Cohen,  Daufresne  and  Kenyon,    Proceeduigs  of  the   Royal 
Society^  1916,  vol.  89,  p.  232. 

-  Dakin,  Presse  Medic  ale  ^  Sept.  30,  191 5. 


8      TREATMENT   OF   INFECTED   WOUNDS 

From  May,  191 5,  it  became  evident  that  wounds 
treated  after  a  certain  method  by  the  aid  of  hypochlorite 
or  the  chloramines  of  Dakin  were  sterihsed,  without  any 
harm  resulting  to  the  tissues  or  the  patient.  From  that 
date,  it  has  been  possible  to  prevent,  in  the  greater 
number  of  cases,  infection  of  wounds,  and  to  abolish, 
almost  entirely,  suppuration  in  hospitals.  At  this  time 
the  method  was  practised  in  some  hospitals  of  the  first 
line  by  le  medecin  principal  Uffoltz,  Directeur  du 
Service  de  sante  d'un  corps  d'armee.  To  him,  and  to 
his  colleagues  is  due  the  merit  of  demonstrating  that 
infection  of  wounds  treated  under  the  ordinary  con- 
ditions of  a  field  hospital  can  be  almost  entirely  done 
away  with. 

During  the  months  of  July  and  September,  191 5, 
Dakin  ^  published  an  account  of  the  substances  which 
gave  these  results,  and  the  mode  of  preparation.  In 
October  of  the  same  year,  M.  Pozzi  demonstrated  in  our 
name  at  the  Academie  de  Medecine  the  principles  which 
are  fundamental  to  the  chemio-therapy  of  wounds.^ 
These  principles  were  later  set  forth  in  a  more  complete 
manner  in  1916,  in  the  Archives  de  Medecine  et  de 
Pharmacie  Militaires.^  On  several  occasions  at  the 
Academie  de  Medecine,  and  at  the  Societe  de  Chirurgie, 
M.  Pozzi,*  spoke  at  length  upon  the  technique  and  upon 
the  results  of  the  method,  which,  from  this  time  forth, 
enabled  us  to  sterilise  infected  wounds,  whether  newly 
inflicted,  or  of  long  standing.     In  communications  made 

^  Dakin,  Ptrsse  Medicate^  loco  citato. 

•  Carrel,   Dakin,   Daufresne,   Dehelly,   and    Dumas,    Presse  JlfJdicale, 
Oct.  II,  1915. 

^  Carrel,  Archives  de  Midicme  et  de  Pharmacie  Militaires^  May,  1916. 

*  Fozzi,  Academie  de  Midicine  et  SociHS  de  Chirurgie^  19 15  and  J916. 


INTRODUCTION  9 

to  the  Societe  de  Chirurgie,  M.  Tuffier^  pointed  out 
the  results  which  it  was  possible  to  obtain  by  the  same 
technique.  Le  medecin  principal  Uffoltz  published  in 
1 916  (January)  an  important  article,^  upon  results 
obtained  in  hospitals  under  his  control,  by  MM.  Ferret, 
Dupuy,  Lemaire,  Hornus,  Perrin,  Vigne,  Moyroud,  etc. 
About  the  same  date,  M.  Pozzi  communicated  in  our 
name  to  the  Academie  de  Medecine  observations  demon- 
strating that  sterilisation  allowed  wounds  to  be  closed, 
in  many  cases,  after  a  period  varying  from  four  to  ten 
days.  On  March  28th,  M.  Pozzi  read  a  paper  on  a  report 
by  M.  Uffoltz  concerning  the  secondary  union  of  wounds. 
On  April  nth,  M.  Perret  read  before  the  Academie 
de  Medecine  a  paper  in  which  he  announced  the  results 
obtained  by  the  sterilisation  of  wounds  in  wards  under 
his  care.  Not  one  of  1 1 1  cases  had  suppurated.  On 
May  2nd,  one  of  us  read  a  paper  at  the  Academie  de 
Medecine  on  the  subject  of  153  wounds  treated  in  the 
hospital  at  Compiegne  during  the  month  of  December, 
191 5.  Of  these  155  wounds,  135  were  closed.  Of  the 
135  successes,  121  were  united  before  the  12th  day. 

On  May  23rd,  M.  Ouenu  demonstrated  at  the 
Societe  de  Chirurgie  the  results  obtained  by  MM. 
Hornus  and  Perrin  in  one  of  the  field  hospitals  under  the 
charge  of  M.  Uffoltz.  These  surgeons  had  treated  121 
wounds  in  their  wards.  In  44  cases  they  had  been  able 
to  suture,  and  the  other  77  cases  were  ready  to  be 
sutured  at  the  moment  of  M.  Quenu's  visit.  At  the 
same  meeting  M.  Tuffier  read  a  paper  by  MM.  Dehelly 
and  Dumas  on  the  sterilisation  and  closure  of  wounds 

'  Tuffier,  Societe  de  Chirurgie,  1 91 5  and  191 6. 

-  Uffoltz,  A^rhives  de  MMicine  et  de  Pharmacie  AliHfaires,  Jan.,  1916. 


lo    TREATMENT   OF   INFECTED   WOUNDS 

in  war.  In  31  out  of  33  cases,  union  by  first  intention 
had  been  obtained  after  secondary  closure.  In  the 
hospital  at  Panne,  M.  Depage  ^  and  his  colleagues  had 
obtained  equal  success  in  the  sterilisation  and  secondary 
closure  of  a  great  number  of  wounds. 

Although  these  results  show  in  unmistakable  manner 
that  infected  wounds  can  be  sterilised  and  sutured,  and 
although  more  than  a  year  has  elapsed  since  the 
technique  was  made  known,  the  chemical  sterilisation  of 
wounds  is  still  an  exceptional  occurrence.  It  is  only  at 
the  hospital  at  Compiegne,  at  M.  Depage's  hospital  at 
Panne,  and  in  two  or  three  territorial  hospitals  that  the 
method  is  employed  in  its  integrity. 

From  the  month  of  September,  191 5,  it  has  been 
possible  to  do  away  with  suppuration  in  hospitals.  But 
our  methods  met  with  so  much  opposition  from  certain 
individuals  at  the  head  of  the  medical  profession  in 
France  that  they  have  been  applied  scarcely  anywhere. 
A  glance  through  the  reports  of  discussions  in  the 
Societe  de  Chirurgie  and  the  Academie  de  Medecine, 
on  the  occasions  when  papers  by  MM.  Pozzi  and  Tuffier 
were  read,  will  show  with  what  culpable  levity  a  method 
which  could  have  saved  a  large  number  of  limbs  and 
lives   was    rejected.^     The    men-^  who   criticised   us    so 

*  Depage,  Bulletin  et  Memoirs  de  la  Societe  de  Chirurgie,  vol.  xlii.  (1916), 
p.  1987. 

2  ".  .  .  et  nous  apporter  cela  d'Amerique,  laissez-moi  rire.  .  .  ." 
M.  Broca,  professeur  a  la  Faculte  de  Medecine  de  Paris,  Jan.  5th,  1916. 
Bulletin  et  Memoires  de  la  Societe  de  Chirurgie  de  Paris,  vol.  xlii.  pp.  104 
and  105. 

3  Especially  should  be  noticed  the  communications  made  in  1915  and 
1916  to  the  Societe  de  Chirurgie  de  Paris  or  at  the  Reunion  chirurgicale 
de  la  IV^  Armee,  by  MM.  Dclbet,  Hartmann,  Broca,  Potherat,  Chapur, 
etc.  Bulletin  et  Memoires  de  la  Societe  de  Chirurgie  and  Presse  Medicate, 
1915-1916. 


INTRODUCTION  ii 

severely  have  taken  the  trouble  neither  to  examine 
our  methods  nor  to  check  our  results.  They  knew 
nothing  of  the  methods  they  discussed.^  Their  re- 
sponsibility is  all  the  greater  because  their  position  at 
the  University  and  in  the  hospitals  of  Paris  has  given 
such  weight  of  authority  to  their  verdict. 

The  aim  of  this  book  is  to  show  how  surgical  steri- 
lisation of  the  greater  number  of  infected  wounds  may 
be  obtained.  In  the  following  pages  we  shall  describe 
the  principles  which  allow  a  given  antiseptic  to  act  in  an 
efficient  manner.  The  application  of  these  principles 
constitutes   a  "  method,"  that  is  to  say,  an  entity,   no 

^  With  regard  to  the  attitude  of  the  Societe  de  Chirurgie,  note  M. 
Pozzi's  communication  to  the  meeting  of  May  17,  1916. 

*'....  In  any  case,  one  should  see  for  oneself  at  Compiegne — only 
two  hours  from  Paris  — the  condition  of  the  wounded  treated  by  the  new 
method.  This  is  what  I  have  already  done  myself,  on  two  occasions, 
when  I  took  part  in  the  memorable  discussions  which  took  place  at  the 
meetings  of  our  Society,  the  5th  and  26th  of  January  ;  and  at  the  Academic 
de  Medecine,  the  nth  of  January  last.  And  it  is  what  I  have  begged  my 
colleagues  to  do,  at  once.  I  am  glad  that,  at  last,  M.  Quenu  has  followed 
my  advice.  The  time  has  come  at  last  to  repair  the  real  injustice  com- 
mitted towards  a  method  which  for  long  months  past  had  displayed  in  vain 
evidence  of  its  value,  which  is  certainly  destined  to  save,  in  the  future 
(as  it  has  already  done  in  the  immediate  past),  a  great  number  of  wounded 
men,  and  to  lessen,  in  almost  every  case,  the  gi-avity  of  mutilations  and 
infirmities. 

*'  In  fact,  after  the  sentence,  almost  of  reproof,  pronounced  against  it 
here,  and  at  the  Academie  de  Medecine  in  the  month  of  January  last, 
there  was  brought  about  amongst  the  young  surgeons  at  the  front  a  sudden 
hesitation  to  apply  the  new  method,  which  at  first  they  had  received  with 
marked  approval.  This  was  emphatically  to  be  regretted.  Further — ^may 
I  be  allowed  to  say  in  all  sincerity — it  is  not  only  the  wounded  to  whom 
this  attitude  of  our  great  learned  Societies  risks  doing  harm,  but  it  is  the 
Societies  themselves,  who,  h priori,  and  without  relying  upon  an  investiga- 
tion easy  to  carry  out  (l'h6pital  Carrel  being  at  Compiegne),  have  publicly 
refused  to  the  treatment  newly  instituted  the  merit  of  originality  and  of 
progress  .  .  .  ." 


12     TREATMENT   OF   INFECTED   WOUNDS 

portion  of  which  should  be  altered  at  random.  The 
deplorable  results  obtained  in  several  hospitals  by 
surgeons  who  believed  they  were  using  our  methods, 
but  who,  in  reality,  were  altering  them  according  to 
their  fancy,  make  clear  the  necessity  for  observing 
exactly  the  directions  which  will  be  laid  down  in  the 
following  pages.  The  best  way  to  learn  the  method  is 
to  see  it  applied.  Hence  this  book  is  especially  intended 
to  recall  essential  details  of  the  technique  to  those  who 
already  know  something  of  its  application. 

Compiegne,  Sept.  i,  191 6. 


CHAPTER  I 

THE    PRINCIPLES    OF    THE   TECHNIQUE 

Destruction  by  chemical  means  of  the  micro-organ- 
isms infecting  a  wound  is  rendered  possible  by  the 
different  resistances  presented  by  the  tissues  equipped 
with  a  circulation,  and  the  microbes  which  are  found  on 
their  surface.  The  idea  must  be  grasped  that  a  given 
antiseptic  substance,  applied  at  a  certain  concentration, 
and  during  a  certain  time,  is  able  to  destroy  microbes 
without  damaging  the  normal  tissues  to  any  appreciable 
extent.  The  chemiotherapy  of  wounds  is  easier  to  realise 
than  that  of  the  blood.  In  the  latter  case  a  substance 
capable  of  destroying  microbes  is  harmful  to  the  cor- 
puscles, because  the  resistance  of  isolated  anatomical 
elements  is  but  little  different  from  that  of  micro- 
organisms. 

The  mere  application  of  an  energetic  antiseptic  sub- 
stance, by  any  form  of  technique  whatsoever,  cannot  be 
relied  upon  to  sterilise  a  wound.  The  success  of  the 
method  which  enables  us  to  render  aseptic  an  infected 
wound  is  not  due  to  the  marvellous  properties  of  a  new 
drug.  It  should  rather  be  attributed  to  a  combination  of 
means,  which  enables  us  to  make  use  of  a  definite  anti- 
septic substance,  under  such  conditions  of  concentration 
and  duration  that  its  action  becomes  efficacious.     This 

13 


14     TREATMENT   OF    INFECTED   WOUNDS 

method  is  a  combination  of  which  each  single  part  is 
essential  to  the  rest.  The  antiseptic  cannot  be  altered 
without  changing  the  manner  of  using  it.  In  the  same 
way  a  modification  of  the  technique  demands  an  anti- 
septic endowed  with  different  chemical  properties. 

The  technique  of  sterilisation  has  been  studied,  not 
by  a  series  of  experiments  in  vitro,  but  actually  upon 
the  wounds  themselves.  While  tracing  the  bacterio- 
logical evolution  of  a  wound  we  have  determined  the 
conditions  under  which  a  given  antiseptic  is  capable 
of  bringing  about  rapidly  the  total  disappearance  of 
microbes.  By  this  means  we  have  determined  that  a 
substance  powerfully  bactericidal,  yet  only  slightly  irri- 
tating, such  as  Dakin's  hypochlorite  of  soda,  will  sterilise 
a  wound  if  it  remain  in  contact  with  the  microbes  during 
a  known  period  of  time  and  at  a  certain  degree  of  con- 
centration. As  the  wound  responds  to  treatment  in 
becoming  sterile,  and  as  the  progress  of  the  sterilisation 
cannot  be  gauged  by  a  mere  clinical  examination,  the 
bacteriological  study  of  the  secretions  is  the  guide  needed 
for  therapeusis. 

The  method,  therefore,  is  based  upon  the  employ- 
ment, rigorously  controlled  by  the  microscope,  of  an 
approved  agent,  under  conditions  of  contact,  of  concen- 
tration, and  of  duration,  established  by  direct  experi- 
ment upon  infected  wounds. 

I.  The  Choice  of  an  Antiseptic 

In  order  to  choose  the  fittest  substance  to  sterilise  an 
infected  wound  we  must  consider,  apart  from  its  bacteri- 
cidal   action,   many  other    factors,  such  as   its   capacity 


THE   PRINCIPLES   OF   THE   TECHNIQUE     15 

for  irritating  the  tissues,  its  toxicity,  its  solubility,  its 
power  of  penetrating  the  tissues,  and  of  being  absorbed 
by  them,  and  the  manner  in  which  it  reacts  with  proteids 
and  other  constituents  of  the  tissues.  The  destruction 
of  bacteria  under  the  influence  of  a  chemical  agent  is 
due  to  the  reaction  of  the  antiseptic  on  the  one  side, 
with,  on  the  other,  proteins  and  other  substances 
which  enter  into  the  constitution  of  micro-organisms. 
Suspended  in  water,  microbes  are  easily  destroyed  by 
antiseptics,  because  the  mixture  contains  no  other  pro- 
teins. But  when  they  are  immersed  in  blood  serum, 
pus,  or  other  exudations,  their  destruction  is  more 
difficult,  because  the  antiseptic  acts  not  only  on  the 
micro-organisms  but  also  on  the  protein  substances  in 
the  midst  of  which  they  are  found.  That  is  precisely 
why  the  value  of  a  substance  intended  for  the  treatment 
of  wounds,  should  be  judged  according  to  its  bactericidal 
action  on  microbes  in  suspension  in  blood-serum  and 
pus,  and  not  upon  microbes  simply  suspended  in  water. 

The  bactericidal  activity  of  all  known  antiseptics  is 
greatly  reduced  by  the  presence  of  blood-serum  or 
analogous  substances.  This  reduction  is  so  great  in 
certain  cases  that  the  substance  employed  under  these 
conditions  practically  loses  all  its  value.  Dakin  and 
Daufresne  have  shown,  in  the  experiments  described 
later  on,  the  enormous  diminution  in  bactericidal  pov/er 
of  certain  antiseptics  under  the  action  of  blood-serum. 
In  these  experiments  the  antiseptic  action  of  substances 
was  estimated  by  the  degree  of  concentration  of  the 
solution  capable  of  destroying  in  two  hours,  at  the 
temperature  of  the  laboratory,  microbes  in  suspension  in 
water  and  in  horse-serum. 


i6     TREATMENT    OF    INFECTED   WOUNDS 

The  technique  followed  by  Daufresne  was  as  follows 
A  series  of  tubes  was  prepared  containing  5  cubic  centi- 
metres of  a  solution  of  the  substance  of  a  degree  of 
concentration  progressively  diminishing.  To  each  tube 
was  added  one  or  two  drops  of  a  culture  (twenty-four 
hours  in  peptonised  bouillon)  of  the  organism  to  be 
studied.  A  control-tube  was  at  the  same  time  prepared 
containing  5  c.c.  of  distilled  water  with  one  drop  of  the 
culture.  The  mixtures  of  antiseptic  and  microbes  were 
carefully  shaken  every  half-hour,  and  kept  at  a  tempera- 
ture of  iS""  to  20^  C.  for  two  hours.  Afterwards  a 
loopful  of  the  liquid  from  each  tube  was  placed  in  each 
of  a  series  of  tubes,  each  containing  3  c.c.  of  bouillon- 
These  tubes  were  placed  in  the  incubator  for  twenty- 
four  hours,  and  kept  at  a  temperature  of  37°  C.  When, 
at  the  end  of  twenty-four  hours,  there  was  no  develop- 
ment, it  was  decided  that  the  degree  of  concentration  of 
the  antiseptic  was  sufficient  to  kill  the  organism.  In- 
complete sterilisation  was  indicated  by  the  growth  of  the 
organism  in  the  bouillon.  Examination  of  the  antiseptic 
action  of  the  substance  in  presence  of  blood- serum  was 
made  in  a  similar  manner,  but  to  the  liquid  contained 
in  the  first  series  of  tubes  were  added  5  c.c.  of  horse- 
serum,   previously  warmed   to  a  temperature  of  55°  or 

In  this  fashion  some  two  hundred  substances  were 
studied  by  Dakin  and  Daufresne.  The  micro-organisms 
which  were  used  as  tests  were  staphylococci,  streptococci, 
the  bacillus  pyocyaneus,  and  the  bacillus  of  Welch.  In 
the  following  table  will  be  found  the  results  of  some 
of  Daufresne's  experiments,  made  by  means  of  a  fresh 
culture  of  staphylococci   on  certain  antiseptics  in  daily 


THE   PRINCIPLES   OF  THE   TECHNIQUE     17 


use.     The  sign  -f  indicates  that  the  culture  is  positive, 


and  the  sign 


that  it  remained  sterile. 


Antiseptics. 

Without  blood-serum. 

With  blood-serum. 

Acid  carbolic     .     .     . 

>i          j>          ... 
Acid  salicylic     .     .     . 

»»          >»          ... 
Hydrogen  peroxide     . 

Iodine 

:  250  — 

:  500  + 

:  2,500  - 

:  5,000  + 

:  3.500  " 
8,000  -f 
100,000  — 
10,000,000  + 
5,000,000  — 
10,000,000  + 
1,000,000  — 
10,000,000  + 
500,000  — 
1,000,000  4- 

I  :  50  - 
I  :  100  + 
I  :  100  - 
I  :  250  + 
I  :  1,700  - 
I  :  2,000  + 
I  :  1,000  — 

I  :  2,500  + 
I  :  25,000  — 
I  :  50,000  4- 
I  :  10,000  — 
I  :  25,000  + 
I  :  1,500  - 
I  :  2,000  + 

Bichloride  of  mercury 

Nitrate  of  silver      .     . 

>»           »>          ... 
Hypochlorite  of  soda  .     . 

This  table  shows  what  feeble  power  is  possessed  by 
an  antiseptic  which  has  had  a  great  vogue — carbolic 
acid.  It  also  demonstrates  that  bichloride  of  mercury, 
which  has  only  a  mediocre  action  on  an  infected  wound, 
nevertheless  kills  the  staphylococcus  in  presence  of  blood- 
serum  of  I  :  25,000.  These  experiments  clearly  show  us 
that  in  the  choice  of  a  suitable  antiseptic  many  qualities 
beside  bactericidal  action  have  to  be  considered ;  it  has 
been  demonstrated  that  bichloride  of  mercury,  nitrate  of 
silver,  and  iodine,  which  have  a  high  germicidal  potency, 
are  nevertheless  the  least  suitable  for  wound  treatment. 
Therefore  it  is  well  to  become  acquainted  with  the 
practical  inconveniences  of  the  substances  we  are  about 
to  examine. 

Phenol  has  a  very  poor  bactericidal  power,  especially 
when  acting  in  the  presence  of  blood-serum.  If  em- 
ployed in  concentration  sufficient  to  render  efficient  its 


i8     TREATMENT   OF   INFECTED   WOUNDS 

germicidal  action,  it  becomes  highly  destructive  to 
normal  tissues. 

Hydrogen  peroxide  solution  gives  encouraging  re- 
sults when  its  bactericidal  action  is  examined  in  a  test- 
tube.  But  on  wounds,  on  the  contrary,  it  has  a  very 
feeble  action,  because  it  decomposes  with  the  greatest 
readiness  under  the  influence  of  the  catalysis  always 
going  on  in  the  tissues  and  in  the  blood  corpuscles. 
Consequently,  its  action  is  only  exerted  during  a  com- 
paratively insignificant  period  of  time.  The  mechanical 
detergent  action  which  results  from  the  rapid  disengage- 
ment of  oxygen  when  in  contact  with  infected  surfaces, 
has  probably  a  greater  value  than  the  antiseptic  action  of 
the  hydrogen  peroxide  itself.  Dakin  i  quotes  on  this 
subject  an  interesting  experiment  which  had  been  com- 
municated to  him  by  Prof  E.  K.  Dunham  of  New  York. 
A  rabbit  which  had  received  an  intra-venous  injection  of 
Welch's  bacillus  (Bacillus  aerogenes  capsulatus  or  Bacillus 
perfringens)  was  killed.  The  infected  liver  was  cut  up 
very  carefully  into  tiny  fragments.  Placed  in  the  incubator 
with  hydrogen  peroxide  solution,  it  was  found  that  the 
volume  of  a  fragment  of  infected  liver  must  not  exceed 
a  millimetre  cube,  if  the  micro-organisms  contained  in  it 
were  to  be  killed.  Should  the  fragments  be  a  little  larger, 
the  bacilli  of  Welch  multiplied  actively.  Hydrogen 
peroxide,  therefore,  may  be  considered  as  having  but  a 
feeble  antiseptic  action,  even  against  anaerobic  microbes. 

Bichloride  of  mercury  readily  loses  the  greater  part 
of  its  antiseptic  power  in  presence  of  pus  and  the  sub- 
.stances  of  which  the  tissues  are  made.  Besides,  it  is 
very  irritating,  even  in  dilute  solution. 

•  Dakin,  Presse  Medicale,  191 5. 


THE    PRINCIPLES   OF  THE   TECHNIQUE      19 

Nitrate  of  silver  has  a  greater  value  than  bichloride 
of  mercury.  But  it  becomes  irritating  when  used  in 
sufficiently  strong  solution.  Many  substances  which 
enter  into  the  composition  of  the  tissues  inhibit  its  action 
in  a  marked  manner.  The  sensitiveness  to  light  of 
silver  compounds  is  also  an  objection  to  their  use. 

Iodine,  so  valuable  for  sterilisation  of  the  skin,  has 
yielded  results  much  less  satisfactory  when  applied  to 
the  disinfection  of  deep  wounds,  because  it  coagulates 
proteins  and  irritates  the  tissues.  The  penetrative  power 
of  iodine  is  feeble.  Treated  by  this  substance,  wounds 
continue  to  suppurate,  and  heal  more  slowly  than  the  rest. 

Hypochlorite  of  soda  has  a  high  germicidal  power 
and  many  other  useful  qualities.  But  the  hypochlorite 
of  soda  found  in  commerce  has  an  extremely  variable 
composition.  Besides,  it  contains  free  alkali,  and  often 
free  chlorine.  Consequently,  it  is  irritating  when  applied 
to  a  wound. 

The  deleterious  action  of  antiseptic  solutions  upon 
living  tissues  should  be  studied  as  carefully  as  their 
bactericidal  action.  It  is,  in  fact,  absolutely  necessary 
that  the  substance  should  be  tolerated  by  the  tissues 
during  a  prolonged  period.  The  disfavour  with  which 
the  antiseptic  method  is  regarded  by  the  majority  of 
surgeons  is  partly  due  to  the  use  of  destructive  sub- 
stances, such  as  carbolic  acid  or  corrosive  sublimate, 
which  have  done  harm  without  sterilising  the  wounds. 

In  a  series  of  experiments  which  he  made  with  Mme. 
Carrel  in  M.  Tufher's  laboratory  at  I'hopital  Beaujon, 
Dakin  studied  the  action  of  a  great  number  of  sub- 
stances on  connective  tissue.  The  experiments  were 
made   on  guinea-pigs.     Small   fragments  of  sponge  of 


20     TREATMENT   OF   INFECTED   WOUNDS 

similar  weight  were  placed  under  the  skin  of  the 
abdominal  wall  by  means  of  a  short  incision  which  was 
immediately  closed  by  a  suture.  On  one  side,  by  means 
of  a  hypodermic  syringe,  i  c.c.  of  the  substance  to  be 
studied  was  injected.  In  the  sponge  placed  on  the 
other  side,  which  served  as  a  control,  i  c.c.  of  physio- 
logical saline  solution  was  injected.  At  the  end  of  forty- 
eight  hours  examination  of  the  region  showed  a  thicken- 
ing, more  or  less  considerable,  of  the  tissues  surrounding 
the  fragment  of  sponge  which  had  received  the  solution. 
By  the  change  in  volume  of  the  sponge,  the  action  of  the 
substance  employed,  upon  connective  tissue  could  be 
estimated.  In  this  manner  carbolic  acid,  iodine,  bi- 
chloride of  mercury  produced  marked  tumefaction.  The 
animals  injected  with  bichloride  of  mercury  usually  died 
rapidly.  Those  injected  with  carbolic  acid  showed  ex- 
tensive necrosis  of  the  abdominal  wall. 

It  was  only  after  having  made  the  comparative  ex- 
amination of  a  large  number  of  substances,  from  the 
point  of  view  of  their  bactericidal  action  and  of  their 
irritating  action  upon  normal  tissues,  that  Dakin  decided 
upon  neutralised  hypochlorite  of  soda  and  chloramines. 

A.  Dakin's  Hypochlorite  of  Soda.  —  The  antiseptic 
properties  of  hypochlorite  of  soda  have  been  known  for  a 
very  long  time.^  But  it  is  not  possible  to  use  hypo- 
chlorite, either  in  the  form  of  eau  de  Javel  or  of  Labar- 
raque's  solution,  for  the  sterilisation  of  wounds,  because 
these  solutions  are  irritating,  and  may  cause  grave  injury 
to  the  tissues.  Because  of  this,  Dakin  endeavoured  to 
lessen  the  irritant  qualities  of  the  hypochlorites  without 
modifying  their  antiseptic  action. 

*  Dakin,  British  Medical  Journal,  1915,  p.  809. 


THE   PRINCIPLES    OF   THE   TECHNIQUE     21 

The  principles  of  the  preparation  of  the  hypochlorite 
solution  by  Dakin  are  as  follows.  A  solution  of  hypo- 
chlorite of  soda  almost  always  contains  free  alkali,  even 
when  it  is  prepared  with  the  greatest  care.  Though 
looked  upon  as  neutral,  it  has  an  alkaline  reaction. 
This  reaction  is  due  not  only  to  the  alkali  which  may 
arise  from  the  mode  of  preparation,  but  also  to  a  hydro- 
lytic  dissociation  of  the  hypochlorite  which  produces  free 
soda  and  hypochlorous  acid. 

The  amount  of  this  dissociation  has  been  measured 
by  Duyk,  and  is  quite  considerable.  It  is  to  the  forma- 
tion of  free  alkali,  therefore,  that  the  irritating  action 
of  hypochlorite  is  due.  The  amount  of  the  hydrolytic 
dissociation  increases  with  the  dilution,  so  that,  from  a 
practical  point  of  view,  a  hypochlorite  cannot  be  rendered 
non-irritant  by  merely  reducing  its  concentration.  Really, 
a  point  is  soon  reached  at  which  the  bactericidal  action 
is  lessened,  while  the  irritating  properties  of  the  solution 
remain.  Besides  these  two  sources  of  free  alkali,  it  must 
not  be  forgotten  that  soda  may  be  liberated  by  the 
action  of  hypochlorite  on  proteins.  A  reaction  takes 
place,  in  which  the  chlorine  of  the  hypochlorite  attaches 
itself  to  the  nitrogen  of  the  proteins,  as  will  be  demon- 
strated later. 

Dakin,  for  the  neutralisation  of  the  alkali  of  the  hypo- 
chlorite of  soda,  made  use  of  the  following  known  facts. 
Blood  and  other  organic  liquids,  and  also  certain  artificial 
saline  solutions  containing  mixtures  of  polybasic  acids, 
such  as  phosphoric  acid,  are  able  to  keep  their  essential 
neutrality,  even  after  the  addition  of  acid  or  alkali.  This 
phenomenon  is  due  to  the  fact  that  the  addition  of  acid 
or  alkali  simply  changes  the  relative  proportion  of  two  or 


22     TREATMENT   OF   INFECTED   WOUNDS 

more  salts  of  the  polybasic  acid  present  in  the  solution. 
Setting  out  from  this  principle,  and  employing  a  feeble 
polybasic  acid  (boric  acid),  Dakin  succeeded  in  preparing 
a  simple  mixture  of  hypochlorites,  which  remains  very 
nearly  neutral  under  all  conditions,  and  which  in  conse- 
quence does  not  irritate  the  tissues.  This  solution  con- 
tains a  mixture  of  hypochlorite  and  polyborate  of  soda 
and  small  quantities  of  free  hypochlorous  acid  and  boric 
acid.  In  this  manner  the  irritating  action  of  caustic  soda 
is  avoided.  In  fact,  if  alkali  should  form,  it  would  be 
immediately  neutralised  by  the  boric  acid  and  the  acid 
borates  present  in  the  solution. 

Dakin's  hypochlorite  differs  from  eau  de  Javel  and 
Labarraque's  solution  in  that  its  destructive  action  upon 
the  tissues  is  very  slight.  Study  of  the  communications 
made  to  the  learned  Societies  of  Paris,  and  particularly 
to  the  Academic  de  Medecine,  shows  that  the  necessity 
for  using  a  non-caustic  antiseptic  has  not  been  grasped. 
Surgeons  do  not  yet  comprehend  that  Dakin's  solution, 
containing  no  free  alkali,  can  be  employed  under  con- 
ditions where  the  use  of  eau  de  Javel  or  Labarraque's 
solution  would  be  absolutely  impossible. 

A  simple  experiment  made  by  Daufresne  in  the 
laboratories  at  Compiegne  will  show  the  essential  differ- 
ence which  exists  between  Dakin's  solution,  on  the  one 
hand,  and  eau  de  Javel  and  Labarraque's  solution  on  the 
other.  In  three  tubes  there  were  placed  Dakin's  solution, 
eau  de  Javel,  and  Labarraque's  liquor.  The  strength  of 
the  thre^  solutions  in  hypochlorite  of  soda  had  pre- 
viously been  brought  to  0"5  per  cent.  A  fragment  of 
skin  from  a  still-born  infant  was  placed  in  each  of  the 
three  tubes.      At  the  end  of  two  hours  the  action  on 


THE   PRINCIPLES   OF   THE   TECHNIQUE     23 

the  skin  of  eau  de  Javel  and  Labarraque's  solution  was 
already  manifest.  The  skin  was  greatly  swollen,  and 
the  slightest  friction  could  detach  the  epidermis  in  a 
fragile  pellicle.  In  the  hours  following  the  process 
continued,  the  fragment  became  completely  transparent, 
and  after  twelve  hours  in  eau  de  Javel,  and  fourteen 
hours  in  Labarraque's  solution,  the  fragment  of  skin 
was  completely  dissociated.  The  tubes  contained  only 
a  powdery  sediment.  The  piece  of  skin  placed  in 
Dakin's  solution  behaved  in  quite  a  different  manner. 
After  two  hours  of  contact  the  epidermis  was  still  very 
adherent,  and  the  aspect  of  the  skin  was  normal.  At 
the  end  of  twenty-four  hours  the  alteration  in  the  tissues 
resembled  that  observed  after  two  hours'  contact  with 
the  solutions  of  Javel  and  Labarraque. 

This  experiment  shows  in  a  very  clear  manner  the 
profound  difference  which  exists,  from  the  biological 
point  of  view,  between  Dakin's  solution  and  the  non- 
neutralised  hypochlorites.  In  a  word,  Dakin's  researches 
allow  us  to  use  to-day  hypochlorite  of  soda  under  con- 
ditions such  that  it  will  sterilise  the  tissues  without 
danger  to  them.  We  shall  see,  later,  that  the  hypo- 
chlorite only  kills  the  microbes  when  its  action  is  ex- 
tended over  a  long  period,  and  it  is  of  a  strength  of 
0*5  per  cent,  (about),  conditions  impossible  to  realise  if 
the  solution  be  caustic. 

Many  other  preparations  of  hypochlorites  have  been 
previously  employed  in  surgery.  L'eau  de  Javel  and 
Labarraque's  solution  are  well  known,  as  well  as  the 
hypochlorites  of  calcium,  potassium,  and  magnesium. 
Since  the  beginning  of  this  war,  eau  de  Javel  has  been 
used  with   good   results.      In    November,    19 14,  in    the 


24     TREATMENT   OF   INFECTED   WOUNDS 

hospital  at  Dunkirk,  MM.  Landry  and  Jacomet  used 
eau  de  Javel  in  "  gas  "  infections.  Mixtures  of  chloride 
of  calcium  and  boric  acid  in  powder  have  been  used 
by  Vincent,  by  Lumiere,  and  by  Lorrain  Smith.  But 
Dakin's  solution,  applied  according  to  the  technique 
which  will  be  described  later,  gives  much  better  results 
than  the  irritating  solutions  employed  up  to  the  present, 
and  than  powders  composed  of  substances  only  partly 
soluble.  The  local  production,  by  a  mixture  of  hypo- 
chlorites in  powder,  of  hypochlorous  acid,  or  of  chlorine, 
in  a  degree  of  concentration  relatively  high,  is  more 
dangerous  for  healthy  tissues  than  the  continued  ap- 
plication of  a  feeble  neutral  solution  of  hypochlorite  of 
soda.  Besides,  a  solution  has  the  advantage  of  pene- 
trating the  recesses  of  deep  wounds.  Speaking  generally, 
the  experiments  we  have  made  with  Dakin  on  substances 
in.  powder,  and  substances  dissolved  in  fatty  vehicles 
such  as  vaselin  or  lanolin,  have  yielded  results  greatly 
inferior  to  those  of  experiments  made  with  watery  solu- 
tions. On  the  other  hand,  it  is  true  that  the  application 
of  a  watery  solution  demands  more  care. 

I.  Bactericidal  Action  of  Dakin's  Solution. — The  bacteri- 
cidal action  of  Dakin's  solution  of  hypochlorite  of  soda 
has  been  studied  by  Daufresne,  using  micro-organisms 
suspended  in  water,  and  in  water  with  the  addition  of 
horse-serum.  Staphylococci  in  suspension  in  water  are 
killed  in  two  hours  by  hypochlorite  of  a  strength  of 
1:500,000  to  1:1,000,000;  whilst,  in  the  presence  of 
horse-serum,  the  concentration  increases^  and  should  be 
I  :  1,500  to  I  :  2,000.  Streptococci  are  killed  more 
rapidly.  B.  pyocyaneus  in  suspension  in  water  is  killed 
in  two  hours  by  a  strength  of  i  :  100,000  to  i  :  1,000,000  ; 


THE   PRINCIPLES    OF   THE   TECHNIQUE     25 

whilst  in  presence  of  horse-serum  a  strength  of  i  :  2,500 
to  I  :  5,000  becomes  necessary.  In  the  experiments 
made  on  mixtures  of  pus  and  hypochlorite,  it  is  found 
that  sterilisation  generally  takes  place  when  two  or  three 
volumes  of  hypochlorite  to  one  volume  of  pus  are  used. 
The  action  of  hypochlorite  naturally  varies  according  to 
tlie  character  of  the  pus. 

The  results  of  these  experiments  in  vitro  are  of  but 
slight  importance,  for  experimental  conditions  vary  too 
greatly  from  the  actual.  In  wounds,  in  fact,  a  small 
quantity  of  pus  is  found  in  contact  with  a  large  quantity 
of  antiseptic,  because  the  solution  of  hypochlorite  is 
constantly  being  renewed.  In  the  experiments  in  vitro, 
tlie  duration  of  the  action  of  the  hypochlorite  upon  the 
microbes  in  suspension  in  the  pus  is  short.  If,  at  the 
end  of  two  or  three  hours,  one  tests  for  the  hypochlorite 
contained  in  the  mixture,  sometimes  it  is  found  that  it 
has  completely  disappeared.  The  hypochlorite,  in  fact, 
rapidly  enters  into  combination  with  the  proteins  of  the 
pus,  and  chemical  analysis  is  no  longer  able  to  dis- 
cover it.  It  is  precisely  because  of  this  rapid  disappear- 
ance of  hypochlorite  when  in  contact  with  secretions, 
that  Dakin's  solution  should  be  continuously  instilled 
into  wounds,  or  if  intermittently,  at  short  intervals. 
Ignorance  of  this  chemical  property  of  the  hypochlorites 
has  led  surgeons  to  be  surprised  that  mixtures  of  pus 
and  hypochlorite  kept  in  the  incubator  for  several  hours 
should  become  favourable  breeding-grounds  for  microbes. 
It  is  quite  evident  that,  after  being  treated  in  this  manner, 
the  mixture  contains  hypochlorite  no  longer. 

The  bactericidal  action  of  Dakin's  hypochlorite  was 
next   studied   in    infected    wounds   themselves.      When 


26     TREATMENT   OF   INFECTED   WOUNDS 


hypochlorite  of  soda  is  applied  to  a  wound  in  such  a 
manner  that  its  degree  of  concentration  remains  constant, 
and  the  duration  of  the   application   is   prolonged,  the 

microbes  disappear  (Fig.  i).  This 
fact  has  been  observed  a  very 
great  number  of  times.  Indeed, 
one  might  affirm  that  it  con- 
stantly happens  when  intimate 
contact  is  established  between 
the  antiseptic  solution  and  the 
organisms.  The  sterilisation  of 
wounds  treated  by  Dakin's  solu- 
tion is  an  established  fact.  But 
it  will  be  well  to  enquire  if  the 
treatment  is  actually  the  deter- 
mining cause  of  the  sterilisation, 
and  if  this  sterilisation  is  due  to 

Fig.     I. — Disappearance    of   the  hypochlorite  of  Soda. 
the    microbes   of    a   his:hlv  /    \      t,  •    i  .      i  ^     i 

(a)  It  might  be  suggested 
that,  in  our  observations,  the 
wounds  grew  sterile  spontaneously. 
In  truth  this  is  hardly  likely,  be- 
cause one  never  sees  a  series  of 
infected  wounds  become  sterile  in  a  few  days.  Neverthe- 
less, this  hypothesis  was  submitted  to  experimental 
analysis.  Choosing  a  wound  whose  various  regions  w  ere 
uniformly  infected,  a  square  of  filter-paper  was  placed  on 
a  selected  spot,  and  kept  constantly  moist  with  hypo- 
chlorite of  soda.  On  another  spot  was  placed  a  square 
of  filter-paper  of  the  same  size.  Then  the  wound  was 
again  covered  with  a  protective  dressing.  At  the  end  of 
twenty-four  hours,  below  the  filter-paper  moistened  with 


MOlSJMai  JijmlS15| 

J0URSJ31    1  |2  ii 

00-4--4--J- 

1     r     i 

^-rt      1 

• 

60      :      \i 

"^ 

■-5 

■^ 

^ 

4n  j---p 

^ 

b; 

1 

->• 

n'\      it         1 

? 

20      It        J,. 

tl                ^ 

f 

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-ID           1            i    ' 

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^^ 

1 

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>  j_  E  1 

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-rlo, — ^\ 

infected  wound,  after  treat- 
ment by  Dakin's  hypo- 
chlorite, May  31st  to  June 
2nd,  1915.  (Case  28.) 
(00  denotes  infinity.  Trans- 
lator.) 


THE   PRINCIPLES    OF   THE   TECHNIQUE     27 

hypochlorite,  a  smooth  surface  of  red  granulations  was 
to  be  seen,  and  the  microbes  had  completely  disappeared. 
Under  the  filter-paper  which  had  not  been  wetted  with 
hypochlorite,  the  granulations  were  irregular  and  pale, 
and  the  microbes  as  numerous  as  before  (Fig.  2).  In 
the  portions  of  the  wound  which  had  not  been  covered 
with  filter-paper,  there  was  no  change  in  the  quantity  of 
microbes. 

In  a  case  where  the  half  of  a  wound  was  dressed 
with  hypochlorite,  and  the  other  half  with  vaselin,  there 
was  complete  disappearance  of  microbes  in  the  region 
treated  with  hypochlorite,  whilst  the  infection  remained 
elsewhere. 

Similar  results  were  obtained  with  deep  wounds. 
Two  shell  fragments  had  penetrated  two  neighbouring 
points  in  the  lumbar  region,  the  two  fragments  were 
removed  at  the  same  time.  One  of  the  wounds  was 
treated  by  the  continuous  instillation  of  hypochlorite, 
and  the  other  by  a  simple  dressing.  The  wound  treated 
remained  painless,  and  the  microbes  disappeared  com- 
pletely from  the  smears  ;  whilst  the  wound  not  treated 
became  painful,  was  surrounded  by  a  red  aureola,  and 
was  the  seat  of  streptococcal  infection.  In  the  seton 
type  of  wounds,  we  could  often  observe  that  the  region 
where  the  hypochlorite  penetrated  was  sterile,  while  the 
portion  where  the  hypochlorite  did  not  penetrate,  still 
held  a  great  number  of  microbes.  Numerous  similar 
observations  showed  in  a  very  distinct  fashion  that  the 
relation  of  cause  and  effect  existed  between  the  treat- 
ment employed  and  the  results  obtained. 

(b)  Next,  it  must  be  made  clear  whether  the  result 
is  due  to  the  antiseptic  action  of  the  hypochlorite,  or  to 


28     TREATMENT   OF   INFECTED   WOUNDS 


the  mechanical  action  of  the  instilled  liquid.  The  follow- 
ing experiments  were  devised  to  elucidate  this  point.  A 
wounded    man    had    upon    his    thigh    two   wounds    of 


MOiS  Janvia 

m 

JOURS  6 1 7 

8 

oo 

' 



-. 

'^^ 

60 

>- 

<; 

i>: 

^ 

40   I-- 

■*^, 

o,^ 

•o 

20  -li; 

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IT* 

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^ 

^ 

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^ 

■^ 

■" 

^> 

V 

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^l 

5        -4 

^, 

J 

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- 

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j__ 

h  — 

\ 

2— . 

\ 

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\ 

! 

±il 

Fig.  2. — Superficial  wound  of  left 
arm.  Comparative  action  on  an 
infected  wound  of  pieces  of  filter- 
paper  soaked  or  not  in  hypochlorite 
of  soda.  The  continuous  line  re- 
presents the  diminution  of  the 
microbes  from  20  to  o  per  field  of 
the  microscope,  and  the  dotted 
line,  the  condition  of  the  "con- 
trol "  portion  of  the  wound.  (Case 
No.  247.) 


Mois    Mai  1915 

JOURS    22  1  23 

na 

00 

, 

—— ^ 

60 

^ 

^    ' 

40 I 

•^ 

V  i-^r 

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i^ 

20  _zi: : 

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f= 

10  ::z^ii5 

<, 

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r     .  _  ..  .  a! ,_  . 

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5   ii__l_i: 

^ 

JL 

^ 

4                          ■ 

f             z& 

\ \__ 

^-— tj 

%-i---1 

]?       1 

Fig.  3. —Superficial  wounds  of  the 
left  thigh.  Comparative  study  of 
the  influence  of  Dakin's  hypo- 
chlorite and  of  physiological  saline 
solution.  Two  wounds  equally 
infected  and  of  the  same  man  were 
treated,  one  by  hypochlorite,  the 
other  by  saline  solution.  These 
two  wounds  contained  from  20  to 
30  microbes  per  microscope  field. 
The  continuous  line  represents  the 
diminution  in  number  of  microbes 
in  24  hours  under  the  influence  of 
hypochlorite.  The  dotted  line  re- 
presents the  state  of  the  wound 
treated  by  saline  solution  at  the 
end  of  the  same  time.  (Case  No. 
52.) 


dimensions  almost  identical,  and  with  bacteriological 
conditions  practically  the  same.  One  was  dressed  with 
hypochlorite  and  the  other  with  physiological  saline 
solution.     At  the  end  of  twenty-four  hours,  the  surface 


THE   PRINCIPLES   OF  THE   TECHNIQUE     29 

of  the  wound  dressed  with  hypochlorite  did  not  show 
a  single  microbe  per  "  field,"  while  the  wound  treated  by- 
saline  solution  had  more  than  thirty  microbes  per  "  field  " 
(Fig.  3).  Other  experiments  were  made  by  means  of 
wounds,  on  the  surfaces  of  which  were  applied  squares 
of  filter-paper  of  similar  dimensions.  One  of  the  squares 
carried  solution  of  hypochlorite,  while  the  other  had 
physiological  saline  solution.  At  the  end  of  twenty-four 
hours,  the  region  situated  under  the  hypochlorite  con- 
tained no  microbes,  while  the  region  treated  by  saline 
solution  had  a  large  number.  Similarly,  observations 
were  made  on  deep  wounds  with  old  lesions.  A  case 
of  fracture  of  the  femur  with  great  loss  of  substance  and 
extensive  osteo-myelitis  of  the  bony  extremities,  was 
observed  for  several  months.  An  india-rubber  tube 
introduced  into  the  suppurating  cavity  permitted  the 
instillation,  during  arranged  periods,  of  hypochlorite,  or 
of  hypertonic  saline  solution.  When  the  case  was  having 
the  hypochlorite,  the  pus  contained  many  microbes  and 
had  no  smell.  When  the  hypertonic  saline  solution  was 
substituted  for  the  hypochlorite,  the  pus  immediately 
gave  out  a  tainted  odour,  and  the  microbes  became  much 
more  numerous.  As  soon  as  the  hypochlorite  was  again 
instilled,  the  odour  disappeared,  and  the  number  of 
microbes  diminished.  Similar  experiments  were  made 
several  times.  It  is  therefore  evident  that  hypochlorite 
acts  by  its  antiseptic  power  and  not  by  mechanical 
means. 

{c)  The  antiseptic  power  of  hypochlorite  is  not  due 
to  its  alkalinity.  In  M.  Tissot's  paper,  read  at  TAcademie 
des  Sciences  by  M.  Dastre,^  that  author  attributed  the 

'  Tissot,  C.  R.  Academie  des  Sciences,  Sept.  13,  1915. 


30    TREATMENT    OF   INFECTED   WOUNDS 

action  of  hypochlorite  of  soda  upon  wounds  to  its 
alkalinity,  and  declared  that  the  treatment  to  which 
Dakin  had  submitted  it  had  the  result  of  enfeebling  its 
power !  Although  M.  Tissot  furnished  in  support  of  his 
opinion  no  precise  observations,  we  have  made  experi- 
ments to  test  if  the  presence  of  an  alkaline  substance  on 
the  surface  of  a  wound  had  any  influence  upon  its 
bacteriological  condition. 

Upon  a  large  surface  wound  on  the  external  aspect 
of  a  limb,  two  squares  of  filter-paper  of  equal  dimensions 
were  placed.  One  of  the  squares  was  moistened  with 
physiological  saline  solution,  and  the  other  with  a  solution 
of  carbonate  of  soda,  0'5  per  cent.  Two  days  afterwards 
it  was  found  that  the  number  of  microbes  under  the 
paper  moistened  with  saline  solution  was  almost  identical 
with  the  number  under  the  paper  moistened  with 
carbonate  of  soda.  This  experiment  was  repeated  on 
other  wounds  wi;h  similar  results.  The  alkaline  solution 
had  no  more  effect  on  the  microbes  present  at  the  surface 
of  a  wound  than  had  physiological  saline  solution. 

2.  Action  of  Hypochlorite  on  Microbial  Toxins. — This 
point  was  considered  in  a  course  of  experiments  made 
by  M.  Auguste  Lumiere.^  In  a  case  of  grave  tetanus, 
he  took  some  cubic  centimetres  of  pus  from  a  highly 
infected  wound  of  the  leg.  This  pus  was  divided  into 
two  equal  parts,  of  which  one  was  brought  to  double  its 
volume  by  the  addition  of  i  per  cent,  solution  of  hypo- 
chlorite, and  the  other  brought  to  the  same  volume  by 
the  addition  of  chloride  of  sodium  solution,  0'8  per  cent. 
After  the  lapse  of  an  hour,  i  c.c.  of  each  of  these 
preparations   was    injected    into   guinea-pigs.      It    was 

'  Auguste  Lumiere,  C.  7^.  Acad^mU  des  Sciences^  March  6,  19 16. 


THE    PRINCIPLES   OF   THE   TECHNIQUE     31 

found  that  the  animals  which  had  received  the  "  control  " 
pus  died  from  tetanus  in  eight  or  ten  days,  whilst  those 
in  which  had  been  injected  pus  with  the  addition  of  hypo- 
chlorite presented  no  symptoms  of  tetanus  and  survived. 

This  experiment  was  repeated  with  pus  containing 
various  microbes,  streptococci,  staphylococci,  perfringens, 
etc.  These  preparations  were  administered  to  guinea- 
pigs  by  subcutaneous  injection  and  to  rabbits  by  intra- 
venous. It  was  demonstrated  that  pus  containing  hypo- 
chlorite gave  reactions  either  slight  or  benign,  while  the 
purulent  fluids  without  added  antiseptic  produced 
evidences  of  infection,  often  ending  in  death. 

M.  Lumiere,  in  another  series  of  experiments,  candle- 
filtered  pus  both  treated  and  not-treated  with  hypo- 
chlorite, and  injected  animals  with  the  filtrates.  Filtrates 
of  pus  treated  with  hypochlorite  produced  no  change  in 
condition  of  the  animals,  while  the  filtrates  from  the 
control  pus  provoked  pyrexia  and  emaciation.  In  short, 
these  filtration  products,  placed  in  contact  in  vitro  with 
leucocytes  and  microbes,  demonstrate  that  phagocytosis 
is  much  more  active  when  the  pus  has  been  treated  with 
hypochlorite. 

M.  Lumiere's  experiments  prove,  therefore,  that  hypo- 
chlorite of  soda  destroys  toxins  contained  in  pus.  This 
destruction  of  toxins  by  oxidising  antiseptics  plays  a 
favourable  part  in  sterilisation,  either  in  allowing  phago- 
cytosis to  become  effectual,  or  in  preventing  the  im- 
pregnation of  the  organism  by  noxious  substances. 
Perhaps  it  explains,  in  part  at  least,  the  rapid  disappear- 
ance of  general  symptoms,  presented  by  patients  suffer- 
ing from  extensive  suppuration,  when  their  wounds  are 
treated  by  Dakin's  solution. 


32     TREAT.MENT   OF   INFECTED    WOUNDS 

3.  Toxicity  of  Dakin's  Solution. — Hypochlorite  of  soda 
is  very  slightly  toxic  to  the  organism,  when  it  is  injected 
on  the  surface  of  wounds,  or,  in  animals,  into  the  sub- 
cutaneous cellular  tissue.  We  have  injected  under  the 
skin  of  the  abdominal  wall  of  guinea-pigs  quantities  of 
antiseptic  relatively  considerable,  without  unfavourable 
result.  For  example,  three  guinea-pigs  weighed  respec- 
tively 565  grammes,  570  grammes,  and  510  grammes. 
These  had  respectively  8  c.c,  ir4  c.c,  and  1275  c.c.  of 
Dakin's  solution,  that  is  to  say,  1/70,  1/50,  and  1/40 
of  their  body-weight.  They  presented  no  abnormal 
symptom,  and  remained  in  good  health. 

Hypochlorite  of  soda,  which  is  harmless  when  sub- 
cutaneously  injected,  is  very  dangerous  if  injected  into 
the  general  circulation.  An  injection  of  ten  cubic  centi- 
metres into  the  marginal  vein  of  the  ear  of  a  large  rabbit 
rapidly  caused  death.  Hypochlorite  of  soda  is  strongly 
haemolytic,  and  therefore  should  never  be  injected  into 
veins.  Indeed,  it  is  prudent  never  to  inject  it  under 
pressure  into  deep  wounds,  in  order  that  it  may  not  be 
absorbed  by  the  tissues.  Amongst  the  numerous  cases 
of  wounded  men  treated  by  hypochlorite  of  soda,  we 
have  never  had  accidents  which  could  be  attributed  to 
a  toxic  action  of  this  substance. 

4.  Action  of  Hypochlorite  on  the  Tissues. — Experi- 
ments made  upon  guinea-pigs  have  already  shown  that 
a  small  quantity  of  hypochlorite  of  soda  injected  into  a 
fragment  of  sponge  placed  under  the  skin,  produces  no 
modification  of  the  tissues  obvious  to  clinical  examination. 
Further,  Dakin's  solution,  instilled  for  several  days, 
sometimes  several  weeks,  over  the  surface  of  a  wound, 
in  a  general  way  sets  up  no  marked  irritation.     At  the 


THE    PRINCIPLES    OF   THE   TECHNIQUE      33 

same  time  the  action  of  hypochlorite  on  the  tissues  is 
much  greater  i7i  vitro  than  in  vivo.  Fragments  of  skin 
placed  in  Dakin's  solution  begin  to  disintegrate  at  the 
end  of  less  than  twenty-four  hours.  Red  corpuscles  are 
almost  immediately  destroyed.  If  pus  be  mixed  in  a 
tube  with  Dakin's  solution,  the  leucocytes  are  rapidly 
attacked. 

However,  in  the  secretions  from  wounds  treated  by 
hypochlorite,  the  polynuclear  cells  are  not  much  altered, 
and  contain  microbes.  It  is  probable  that  phagocytosis 
takes  places  in  the  sides  of  the  wound  under  shelter  of 
the  antiseptic  which  is  found  on  the  surface.  Tissues 
deprived  of  circulation  dissolve,  and  the  surface  of  the 
tissues  rapidly  cleans  up.  When  the  wall  of  a  vessel  is 
gangrenous,  the  loosening  of  the  dead  fragment  comes 
about  more  rapidly  than  if  the  wound  were  left  to  itself 
Even  the  clots  which  sometimes  close  vascular  wounds 
may  dissolve  under  the  influence  of  hypochlorite.  There- 
fore the  state  of  the  vessels  at  the  time  of  intervention 
must  be  carefully  looked  into,  so  as  to  ensure  reliable 
haemostasis. 

In  a  word,  Dakin's  solution  possesses  a  concentration 
which  allows  one  to  make  use  of  the  differences  of 
resistance  presented,  on  the  one  hand,  by  microbes,  free 
anatomical  elements,  and  necrosed  tissues  :  and  on  the 
other  hand,  normal  tissues  equipped  with  a  circulation 
It  destroys  the  first  and  does  not  damage  the  second. 
It  is  important  to  know  to  what  extent  it  acts  on  living 
tissues.  In  order  to  estimate  its  action,  the  progress  of 
cicatrisation  of  wounds  treated  by  hypochlorite  has  been 
studied  by  us. 

Certain    technical    difficulties  are  presented    by  this 

3 


34    TREATMENT   OF   INFECTED   WOUNDS 

research.  It  is  essentially  necessary  that  the  conditions 
of  the  wounds  whose  healing  is  being  studied,  and 
particularly  their  microbial  state,  should  not  vary 
throughout  the  duration  of  the  experiments.  Should 
these  conditions  vary,  one  may  no  longer  attribute  to 
the  substance  employed' the  eventual  modifications  in 
the  progress  of  cicatrisation.  Furthermore,  the  surface 
of  wounds,  in  spite  of  the  irregularity  of  their  outline, 
must  be  measured  exactly. 

Up  to  the  present,  no  one  has  taken  the  trouble  to 
study  in  any  precise  manner  the  factors  capable  of 
modifying  the  rapidity  of  cicatrisation.  The  bacterio- 
logical condition  of  wounds  the  subject  of  experiment 
has  not  hitherto  been  taken  into  account.  It  is  recog- 
nised, however,  that  the  presence  of  microbes  on  the 
surface  of  a  wound  has  a  profound  effect  on  the  progress 
of  repair.  In  all  the  forms  of  technique  hitherto  em- 
ployed, this  truly  important  omission  destroys  the  value 
of  all  the  experiments  on  and  observations  of  substances 
supposed  to  aid  cicatrisation.  This  error  in  technique 
explains  the  contradictions  found  in  all  medical  publica- 
tions on  the  subject  of  topical  applications  in  the 
treatment  of  wounds.  Every  surgeon  attributes  a  power 
more  or  less  marvellous  to  some  substance  which  the 
surgeon  of  the  next  hospital  looks  on  as  insignificant. 

In  the  same  way,  estimation  of  the  progress  of 
cicatrisation  has  always  been  left  to  individual  opinion. 
As  a  matter  of  fact,  it  has  never  been  sought  to  devise 
a  technique  which  would  permit  exact  measurement  of 
the  surface  of  a  wound,  with  estimation  in  square  centi- 
metres of  the  amount  by  which  it  lessens  day  by  day. 
The    ignorance   we   manifest,   after    so    many   ages    of 


THE    PRINCIPLES    OF   THE   TECHNIQUE     35 

surgical  practice,  of  the  real  influence  of  the  substances 
used  in  treating  wounds,  is  only  due  to  the  absence  of 
scientific  method.  To  obtain  exact  data  on  this  subject, 
it  was  necessary  in  the  first  place  to  experiment  on 
wounds  placed  under  conditions  which  remain  unchanged 
throughout  the  duration  of  the  observations,  and  after- 
wards to  devise  a  method  which  would  allow  the  pro- 
gress of  cicatrisation  to  be  measured. 

{a)  The  Conditions  of  the  Wounds. — The  wound  must 
be  that  of  a  man  immobilised  in  bed,  and  whose  general 
state  does  not  vary  during  the  period  of  observation. 
The  bacteriological  state  of  the  wound  plays  an  im- 
portant part  in  the  progress  of  cicatrisation.  Rapidity 
of  repair  varies  according  to  the  nature  and  the  volume 
of  the  infection.  When  microbes  are  allowed  to  multiply 
on  the  surface  of  the  wound,  it  is  impossible  to  know 
if  the  modifications  of  cicatrisation  are  due  to  direct 
action  of  the  substance  experimented  with  upon  the 
tissues,  or  to  a  favourable  or  unfavourable  action  of  this 
substance  on  the  microbial  flora ;  or  to  the  algebraic 
sum  of  the  two  causes.  Therefore  the  daily  control  of 
the  state  of  the  wound,  by  means  of  the  microscope,  is 
indispensable,  to  avoid  a  false  interpretation  of  the  ex- 
perimental results. 

The  experiments  have  been  made  on  surface  wounds, 
and  sometimes  on  deep  wounds.  Wounds  of  regular 
perimeter  were  preferred  to  those  whose  margins  were 
torn.  Wounds  of  elongated  form  were  specially  chosen, 
so  that  one  half  could  be  treated  by  a  substance,  while 
the  other  half  served  as  a  control.  Or,  better  still, 
wounds  of  nearly  equal  size  were  used,  situated  in  the 
corresponding  region  in  the  same  individual.     One  of 


36     TREATMENT   OF   INFECTED  WOUNDS 

the  wounds  was  dressed  with  a  substance  to  be  tested, 
while  the  other  served  as  a  control. 

Every  day  the  bacteriological  condition  of  the  wound 
was  examined  by  the  aid  of  "  smears,"  and  sometimes  of 
cultures.  As  microbes  were  found,  steps  were  taken 
to  eliminate  them.  The  granulating  surface  and  the 
neighbouring  skin  were  washed  carefully  with  neutral 
oleate  of  soda.  Then  the  granulations  were  sterilised 
by  means  of  hypochlorite  of  soda  or  of  chloramine. 
When  the  bacteriological  examination  showed  that 
sterilisation  was  complete,  the  wound  was  dressed, 
either  with  oleate  of  soda,  or  stearate  of  soda  containing 
small  quantities  of  antiseptic,  or  with  vaseline  or  saline 
solution.  In  this  manner  it  was  possible  to  keep  wounds 
almost  completely  aseptic.  The  daily  bacteriological 
examination  allowed  reappearance  of  the  infection  to  be 
discovered,  and  allowance  to  be  made  for  it  in  the  inter- 
pretation of  the  experiments.  On  wounds  thus  prepared 
the  action  of  the  substances  was  studied. 

(I?)  Teckniqtie  of  the  Measitrement  of  Wounds. — In 
most  cases  the  progress  of  repair  was  studied  on  surface 
wounds,  and  only  rarely  in  deep  wounds.  The  surface 
of  a  wound  was  measured  in  the  following  manner.  A 
sheet  of  thin  celluloid  was  applied  over  the  surface  of 
the  wound.  By  the  aid  of  a  pencil  (used  for  marking 
glass)  the  outline  of  the  epithelial  margin  was  traced, 
and  in  every  case  where  it  was  possible,  the  contour  of 
the  cicatrix  at  its  union  with  sound  skin.  The  drawing 
thus  obtained  was  transferred  to  a  sheet  of  ordinary 
paper.  Then,  with  the  aid  of  a  planimeter,  the  area 
of  the  wound,  properly  so  called,  was  measured,  also 
that  of  the  surface  of  the  wound  increased  by  that  of  the 


THE   PRINCIPLES   OF   THE   TECHNIQUE     n 

cicatrix.  Thus  in  square  centimetres  was  obtained  the 
area  of  the  two  surfaces,  and,  by  subtracting  the  first 
from  the  second,  the  area  of  the  surface  of  cicatricial 
tissue  was  obtained.  When  a  deep  wound  was  in  ques- 
tion, its  capacity  was  obtained  by  filling  it  with  water 
and  so  measuring  the  volume. 

Graphic  representation  of  the  cicatrisation  of  a  wound 
was  obtained  in  the  following  manner.     Time  was  repre- 


Stmt 


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Fig.  4. — Cicatrisation  curve  of  an 
aseptic  wound.  Surface,  expressed 
in  square  centimetres,  forms  tlae 
ordinates,  whilst  time,  in  days,  the 
absciss£e.     (Case  221.) 


ilDecfifi  25 


Fig.  5. — Curves,  observed  and  calculated, 
for  the  same  wound.  By  means  of 
observations  made  the  17th  and  21st  of 
Dec,  the  progress  of  cicatrisation  was 
calculated  according  to  the  formula  of 
Lecomte  du  Nouy.  A  continuous  line  re- 
presents  the  observed  curve,  and  a  dotted 
line  the  calculated  curve.  The  coinci- 
dence of  the  two  curves  is  almost  perfect. 
(Case  221.) 


sented  in  abscissae  and  surface  in  ordinates.  Curves  were 
thus  obtained  which  enabled  one,  day  by  day,  to  estimate 
the  variations  of  the  surface  and  those  of  the  cicatrix. 
Thus  the  parts  taken  by  connective  and  epithelial  tissues 
in  repair  may  be  observed.  It  is  known  that  the  curve 
of  cicatrisation  of  a  wound  is  of  geometrical  form  (Fig.  4)^ 
and  that  Lecomte  du  Nouy  has  found  its  algebraic 
expression.^ 


1  Carrel,   Journal  of  the  American   Medical  Association,    1910,  and 


38    TREATMENT   OF   INFECTED   WOUNDS 

After  one  or  two  observations  the  curve  of  a  wound 
was  calculated,  and  the  observed  curve  was  traced  on 
the  same  sheet  (Fig.  5).  Thus  the  abnormal  variations 
in  progress  of  the  repair  of  the  wound,  which  manifest 
themselves  by  the  divergence  of  the  observed  curve 
from  the  calculated  curve,  can  be  ascertained.  As  we 
possess  also  the  chart  of  the  bacteriological  condition 
of  the  wound,  it  is  easy  to  estimate  almost  exactly  the 
part  played  in  the  progress  of  repair  by  the  substance 
being  studied.  By  means  of  this  method  the  action  of 
hypochlorite  of  soda  upon  the  repair  of  wounds  was 
examined.  Experiments  were  successively  made  upon 
infected  wounds,  and  upon  those  surgically  sterile,  that  is 
to  say,  wounds  whose  secretions  examined  by  means 
of  "  smears  "  no  longer  contained  microbes. 

(c)  Action  of  Hypochlorite  iipoji  the  Cicatrisation  of 
an  Infected  Wonnd. — Many  experiments  were  made 
upon  surface-wounds  whose  curves  of  cicatrisation  were 
known,  and  of  which  the  bacteriological  condition  was 
recorded.  These  wounds  generally  showed  from  five  to 
twenty  microbes  per  microscope  field,  and  the  observed 
curve  of  cicatrisation  showed  a  slighter  fall  than  the 
calculated  curve  (Figs.  6  and  7).  A  perforated  tube 
was  applied  to  the  surface  of  the  wound  and  Dakin's 
solution  instilled  every  two  hours.  In  all  cases  without 
exception  cicatrisation  was  hastened  and  the  curve  of 
cicatrisation  dropped  (Figs.  8  and  9).  The  speed  of  the 
repair  often  increased  in  such  a  manner  that  the  observed 
curve  rejoined  the  calculated  curve,  but  without  ever 
having  a  more  rapid  fall  than  that  of  an  aseptic  wound. 

Journal  of  Expcrivuntal  MedicinCy  1916.     Lecomte  du  ^o\x.y .,  J our?ial  of 
ExpctiinaUal  Medicine^  Nov.,  1916.     A.  Harlmann,  T/iese  de  Paris ^  1916. 


THE    PRINCIPLES    OF   THE   TECHNIQUE     39 

Therefore  there  was  no  accelerating  action  due  to  the 
hypochlorite. 

The    rapidity    of    the    cicatrisation    in   presence    of 
Dakin's  solution  was  sometimes  considerable.     A  wound 


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Fig.  6. — Cicatrisation  curve  of  a  wound 
of  the  abdominal  wall.  Slowing  down 
of  cicatrisation  from  Feb.  loth  to  Feb. 
1 8th,  due  to  a  re-infection.  Accelera- 
tion from  Feb.  i8th  to  Feb.  22nd, 
under  the  influence  of  Dakin's  solu- 
tion.    (Case  327.) 


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Fig.  7. — Curve  indicating  the 
bacteriological  condition  of  the 
preceding  wound  from  Feb.  4th 
to  Feb.  2ist.  The  slowing  down 
of  cicatrisation  coincides  with  a 
re-infection  of  the  wound  which 
reached  its  maximum  Feb.  i6th, 
and  the  acceleration  coincides 
with  the  sterilisation  which  oc- 
curred Feb.  18th.     (Case  327.) 


of  the  leg,  wide  and  of  long  standing,  communicating 
with  an  unsterilised  bone  injury,  yielding  a  great  number 
of  microbes  from  its  surface,  was  healing  very  slowly. 
The  cicatrisation  curve  was  dropping  only  slightly. 
This  wound   had    a   surface   of  75   square   centimetres. 


40     TREATMENT   OF   INFECTED   WOUNDS 


13  15  17  1£'  21  iJ  25  if  2S?1    3 
Nov  JOOC 

P'iG.  8. — Influence  of  the  sterilisation  of  a  wound  on  the  progress  of  cicatrisa- 
tion. The  cicatrisation  curve  shows  how  a  sluggish-looking  and  highly 
infected  wound  steadily  enlarged  from  6  to  15  square  centimetres  from 
the  14th  to  the  29th  of  Nov.  It  was  sterilised  on  the  29th  of  Nov. 
Instantly  cicatrisation  commenced  and  its  course  followed  a  geometric 
curve. 


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Fig.  9. — Bacteriological  curve  of  the  preceding  wound.  The  graph  shows 
that,  under  the  influence  of  Dakin's  hypochlorite,  the  number  of  microbes, 
at  first  infinite,  rapidly  dropped.  The  coincidence  between  the  date  of 
sterilisation  of  the  wound  and  that  of  the  beginning  of  normal  cicatrisation 
should  be  noticed. 


THE    PRINCIPLES    OF   THE   TECHNIQUE     41 

As  soon  as  it  was  treated  with  Dakin's  solution  the 
curve  fell  sharply.  In  four  days  the  wound  lessened 
by  28  square  centimetres,  and  during  the  following  days 
the  repair  continued  at  approximately  the  same  rate.  It 
should  be  noticed  that  the  sterilisation  chart  showed  at 
the  same  time  a  considerable  lessening  in  the  number  of 
microbes.  The  same  phenomenon  was  observed  in  all 
wounds  uniformly  infected,  and  cicatrising  with  a  known 
rapidity,  which  were  treated  with  Dakin's  solution.  With 
the  exception  of  those  containing  a  foreign  body,  all 
wounds  responded  to  the  treatment.  To  remove  the 
foreign  body  was  to  ensure  that  the  wound  would  follow 
the  general  rule. 

Upon  deep  wounds  few  observations  were  made. 
However,  some  experiments  were  carried  out  of  the 
following  type.  A  collection  of  pus  had  formed  on  the 
antero-external  aspect  of  the  leg  of  a  man  with  arthritis 
of  the  knee.  This  collection,  which  was  accompanied  by 
a  rise  of  temperature,  was  opened  at  its  upper  part  and 
the  pus  evacuated.  The  next  day  the  wound  was 
washed  with  Ringer's  solution,  and  its  capacity  measured 
26  c.c.  The  wound  was  irrigated  with  hypochlorite. 
Twenty-four  hours  later  the  suppuration  had  disappeared. 
In  the  bottom  of  the  cavity  a  little  liquid  was  found, 
syrupy,  yellow,  transparent.  The  secretions  only  con- 
tained one  coccus  per  microscope  field.  The  volume  of 
the  cavity  now  was  not  more  than  7  c.c.  Forty-eight 
hours  later  it  was  reduced  to  2  cc,  and  the  wound  was 
completely  sterile.  Then  it  closed.  In  short,  an 
abscess  cavity  of  26  c.c.  was  sterilised  and  completely 
closed  in  four  days.  Similar  experiments  were  made, 
and  yielded  results  comparable.     But  the  diminution  in 


42     TREATMENT   OF   INFECTED   WOUNDS 

volume  of  deep  wounds  comes  about  in  a  more  irregular 
manner  than  the  cicatrisation  of  surface-wounds.  It  was 
upon  the  latter,  therefore,  that  the  majority  of  the  experi- 
ments were  made. 

In  order  to  obtain  more  strictly  controlled  observa- 
tions, experiments  were  made  on  different  parts  of  the 
same  w^ound.  For  example,  two  strips  of  filter-paper 
were  applied  at  the  upper  and  lower  extremities  of  a 
wound  of  the  external  aspect  of  the  arm,  with  fracture. 
Each  strip  stretched  from  one  margin  of  the  wound  to 
the  other,  over  the  granulations,  after  the  manner  of  a 
bridge.  The  previous  bacteriological  examination  had 
shown  that  the  whole  surface  of  the  wound  was  uni- 
formly infected.  The  filter-paper  at  the  lower  part  of 
the  wound  received  an  instillation  of  Dakin's  hypo- 
chlorite every  two  hours,  whilst  the  filter-paper  at  the 
upper  part  was  not  moistened  (Fig.  lO  and  Fig.  1 1). 

At  the  end  of  three  days  it  was  obvious  that  the 
edges  of  the  wound  were  not  altered  in  the  upper  region , 
but  that,  in  the  lower  part  of  the  wound,  cicatrisation 
had  progressed  much  more  quickly.  The  parts  covered 
by  filter-paper  moistened  with  hypochlorite  showed  granu- 
lations softer  and  redder  than  those  in  the  other  regions 
of  the  wound.  The  change  in  the  appearance  of  the 
granulations  followed  a  transverse  line  very  closely  corre- 
sponding to  the  upper  border  of  the  filter-paper.  A 
marked  acceleration  of  the  cicatrisation,  therefore,  had 
taken  place  in  the  region  treated  by  Dakin's  solution 
(Fig.  ii).  At  the  same  time  the  bacteriological  ex- 
amination showed  that  the  microbial  flora  were  not 
modified  over  the  untreated  part  of  the  surface  of  the 
wound,   whilst   in    the    region   covered    by    filter-paper 


THE   PRINCIPLES    OF   THE   TECHNIQUE     43 

soaked  in  hypochlorite,  microbes  had  completely  dis- 
appeared. In  other  experiments,  where  a  part  of  the 
infected  wound  was  dressed  with  vaselin,  and  another 
part  with  hypochlorite  of  soda,  there  was  to  be  observed, 
in  similar  fashion,  acceleration  of  cicatrisation  in  the 
region  treated  by  hypochlorite. 


-w^ 


Fig.  10. — Influence  of  hypo- 
chlorite on  an  infected 
wound.  Wound  on  the  ex- 
ternal aspect  of  the  arm 
presenting  an  infection  of 
cutaneous  origin.  A,  con- 
trol filter-paper.  B,  filter- 
paper  soaked  in  Dakin's 
hypochlorite. 


Fig.  II. — The  same  wound 
three  days  later.  The  lessen- 
ing of  the  wound  at  the 
level  of  the  control  paper  A 
is  of  the  slightest.  Beneath 
the  filter-paper  B,  the  in- 
fluence of  the  hypochlorite 
is  manifest ;  the  epithelial 
margin  has  greatly  advanced , 
and  the  wound  has  lessened 
in  a  well-marked  manner. 


There  was,  therefore,  coincidence  between  the  acce- 
leration of  cicatrisation  and  the  application  of  Dakin's 
hypochlorite  under  certain  conditions,  to  the  surface  of 
the  wound.  We  might,  therefore,  have  been  tempted  to 
attribute  to  the  hypochlorite  of  soda  a  stimulating  action 
on  cicatrisation.  But  as  the  wounds  submitted  to  ex- 
periment were  infected,  and  the  bacteriological  charts 
also  showed  a  coincidence  between  the  disappearance  of 


44     TREATMENT   OF   INFECTED   WOUNDS 

the  microbes  and  the  acceleration  of  cicatrisation,  it  was 
probable  that  the  cicatrising  influence  of  the  hypochlorite 
of  soda  was  only  apparent.  In  fact,  the  following  ex- 
periments showed  that  hypochlorite  of  soda  exercises  no 
active  influence  on  wounds  already  aseptic. 

{d)  Action  of  Hypochlorite  upon  tlu  Cicatrisation  of 
an  Aseptic  Wound.  — In  order  to  keep  aseptic  wounds 
sterile  while  their  cicatrisation  is  being  studied,  hypo- 
chlorite of  soda  is  applied  to  the  surface  during  periods 
more  or  less  long.  But  the  rapidity  of  repair  of  these 
aseptic  wounds,  treated  by  means  of  hypochlorite,  is 
not  altered,  and  the  curves  do  not  show  a  more  marked 
fall.  This  shows  that  the  hypochlorite  of  soda  has  no 
cicatrising  effect,  and  that  the  acceleration  which  it 
produced  in  the  repair  of  infected  wounds  is  due  simply 
to  the  suppression  of  microbes.  Under  the  actual  con- 
ditions of  the  experiments,  hypochlorite  does  not  delay 
the  repair  of  wounds  moistened  every  two  hours  with 
0*5  'per  cent.  Dakin's  solution.  Or  rather,  any  delay 
produced  by  the  action  of  the  hypochlorite  is  too  slight 
to  be  evident. 

We  have  endeavoured  to  study  this  possible  retard- 
ing action  of  hypochlorite  with  the  help  of  a  more  precise 
form  of  technique.  On  a  large  wound  taking  up  the 
external  aspect  of  the  arm,  repeated  bacteriological  ex- 
aminations had  shown  the  absence  of  microbes.  The 
lower  half  of  the  wound  was  covered  with  a  piece  of 
gauze  moistened  every  two  hours  with  Dakin's  solution, 
whilst  the  upper  half  was  dressed  with  vaselin.  At  the 
end  of  four  days  a  tracing  of  the  wound  was  taken,  and, 
on  comparing  it  with  the  preceding  tracing,  it  was  seen 
that  the  epithelial  border  had  progressed  a  little  more 


THE    PRINCIPLES    OF   THE   TECHNIQUE     45 


rapidly  under  the  vaselin  than  under  the   hypochlorite 
(Fig.  12). 

At  this  time  both  the  upper  and  lower  parts  of  the 
wound  were  still  aseptic.  It  would  seem,  therefore,  that 
the  hypochlorite  of  soda  had  slightly  retarded  the  healing 


,./>-r:. 


Fig.  12. — Influence  of  hypochlorite  on  a 
sterile  wound.  The  continuous  outline 
represents  the  contour  of  a  wound  of 
the  outer  region  of  the  arm  which  was 
sterile,  Dec.  i6.  The  half  A  was  dressed 
with  vaselin,  and  the  half  B  with  hypo- 
chlorite. The  dotted  line  represents 
the  state  of  the  wound  Dec.  20.  It 
shows  that  the  part  A  dressed  with 
vaselin  has  healed  a  little  more  quickly 
than  the  part  B  dressed  with  hypo- 
chlorite. 


Fig.  13. — Influence  of  hypochlorite 
on  an  infected  wound.  The  pre- 
ceding wound,  under  the  influence 
of  vaselin,  became  slightly  re- 
infected. The  dressings,  however, 
were  continued,  the  part  A  with 
vaselin,  the  part  B  with  hypo- 
chlorite. The  continuous  outUne 
represents  the  state  of  the  wound 
Dec.  20.  The  dotted  line  repre- 
sents the  state  of  the  wound  Dec. 
24.  It  is  seen  that  the  cicatrisation 
has  taken  place  more  rapidly  in 
the  part  B,  dressed  with  hypo- 
chlorite, than  in  the  part  A,  dressed 
with  vaselin. 


of  an  aseptic  wound.  But  this  retarding  action  was 
much  feebler  than  the  action  of  certain  microbes,  as  the 
later  history  of  the  experiment  showed.  The  wound 
was   still   bein^  dressed    with  vaselin  and  hypochlorite. 


46     TREATMENT   OF   INFECTED   WOUNDS 

Bacteria  soon  appeared  in  the  region  dressed  with 
vaselin,  whilst  that  covered  by  hypochlorite  remained 
sterile.  A  new  tracing  was  taken,  and,  on  comparing  it 
with  the  preceding,  it  was  found  that  the  rapidity  of 
healing  had  become  greater  under  the  hypochlorite  than 
under  the  vaselin  (Fig.  13).  When  physiological  saline 
solution  was  used  instead  of  vaselin,  similar  results  were 
obtained. 

In  short,  in  the  healing  of  an  infected  wound  the 
acceleration  produced  by  hypochlorite  is  due  to  its  anti- 
septic power.  Hypochlorite  does  not  appear  to  have 
any  marked  action  on  the  tissues  in  the  direction  of 
cicatrisation,  when  it  is  used  under  the  conditions  of  our 
experiments.  Probably  it  has  a  slightly  retarding  effect 
on  the  healing  of  aseptic  wounds.  But  in  practice  this 
influence  is  negligible. 

Dakin's  solution,  therefore,  we  may  conclude,  when 
applied  under  suitable  conditions,  does  not  harm  in  any 
appreciable  manner,  tissues  under  repair,  which  is 
contrary  to  the  belief  of  most  surgeons. 

5.  Mode  of  Action  of  Hypochlorite. — Dakin  attributes 
the  bactericidal  action  of  the  hypochlorites  to  a  chemical 
reaction  similar  to  that  which  takes  place  between 
ammonia  and  a  hypochlorite,  and  results  in  the  simplest 
of  the  chloramines,  as  Raschig  demonstrated  long  ago. 
The  destruction  of  micro-organisms  by  an  antiseptic  is  due 
probably  to  chemical  modifications  produced  in  the  sub- 
stances constituting  living  cells,  either  by  the  direct  action 
of  the  antiseptic,  or  by  the  action  of  products  resulting 
from  the  combination  of  the  antiseptic  with  the  substances 
in  the  midst  of  which  the  micro-organisms  are  found. 
Amongst   the  substances  contained  in  living  cells  and 


THE    PRINCIPLES    OF  THE   TECHNIQUE     47 

capable  of  reacting  with  hypochlorites,  proteins  play 
probably  the  chief  role.  The  action  of  hypochlorites  on 
proteid  matters  consists,  at  least  in  part,  in  the  substitu- 
tion of  chlorine  for  hydrogen  in  some  of  the  NH  groups, 
and,  afterwards,  in  the  formation  of  substances  belong- 
ing to  the  group  of  chloramines.  Dakin  ^  believes  that 
the  property  possessed  by  hypochlorites  of  attacking 
proteid  matters,  forming  compounds  in  which  the  halo- 
gen element  is  directly  attached  to  the  nitrogen,  is 
closely  bound  up  with  their  bactericidal  action. 

This  hypothesis  is  supported  by  the  following  observa- 
tions. Free  chlorine,  bromine,  and  iodine  vary  only 
slightly  in  their  germicidal  power.  But  if  the  halogen 
element  is  converted  into  the  hypochlorite  or  the  hypo- 
bromite,  a  strongly  marked  difference  appears.  The 
bactericidal  action  of  hypochlorites  on  staphylococci  sus- 
pended in  water,  is  almost  equal  to  that  of  free  chlorine, 
whilst  that  of  hypobromites  is  only  equivalent  to  about 
one-hundredth  of  that  of  free  bromine.  The  bactericidal 
action  of  hypoiodite  is  almost  nil.  The  insignificant 
bactericidal  power  of  hypobromites  and  hypoiodites  coin- 
cides with  their  feeble  capacity  for  reaction  with  proteins 
and  amino-acids. 

It  is  also  interesting  to  consider  why  hypochlorites, 
which  destroy  the  skin  in  vitro,  leave  unharmed  living 
tissues  and  do  not  interfere  with  the  healing  of  wounds. 

Soda,  it  is  well  known,  produces  immediate  dissolu- 
tion of  the  tissues.  Fiessinger's  experiments,  upon  the 
rapidity  of  dissolution  of  leucocytes,  confirms  the  fact 
that  the  solvent  action  of  the  hyposulphites  is  a  function 

^  Dakin,  Cohen,   Daufresne,  and    Kenyon,  Proceedings  of  the   Royal 
Society  f  191 6. 


48     TREATMENT   OF   INFECTED    WOUNDS 

of  their  soda  content.  Fiessinger  also  ascertained  that 
this  action  diminishes  according  as  hypochlorites  contain- 
ing quantities  greater  or  less  of  soda  are  used.  Dau- 
fresne's  experiments,  which  we  have  already  quoted, 
demonstrate  plainly  that  Labarraque's  solution,  which 
contains  free  alkali,  causes  dissolution  of  skin  at  a 
moment  when  Dakin's  solution  has  not  yet  produced 
any  perceptible  lesion. 

Tissues  provided  with  a  normal  circulation  resist 
perfectly  the  action  of  Dakin's  solution  under  the  con- 
ditions of  our  experiments.  Guillaumin  and  Vienne 
attribute^  this  resistance  to  the  following  phenomenon. 
Take  an  alkaline  solution  of  such  concentration  that  it 
hydrolyses  and  dissolves  the  fragment  of  tissue  placed 
in  it.  If  a  certain  quantity  of  neutral  salt  be  added, 
it  is  known  that  the  tissue  can  be  immersed  in  the 
solution  thus  modified,  without  its  structure  becoming 
altered.  Guillaumin  and  Vienne  made  the  following 
experiment.  Fragments  of  skin  were  placed  in  a  3 
per  cent,  solution  of  soda,  to  which  had  been  added  12 
per  cent,  sodium  chloride.  Other  portions  of  skin  were 
placed  in  3  per  cent,  solution  of  soda  to  serve  as 
controls.  The  skin  immersed  in  the  solution  containing 
chloride  remained  intact,  while  the  control  fragments 
swelled  up  and  became  transparent.  However,  analysis 
showed  that  the  same  quantity  of  alkali  had  been 
absorbed  by  the  skin  in  each  case.  This  important 
process  is  known  in  tanneries  as  "pickling."  Guillaumin 
and  Vienne  consider  it  the  reason  why  tissues  are  not 
injured  by  hypochlorite. 

^  Guillaumin  et  Vienne,  Archhes  de  Mklecine  et  de  Pharniacie  militaire^ 
1916. 


THE    PRINCIPLES    OF   THE   TECHNIQUE     49 

Whatever  may  be  the  explanation  of  the  resistance 
of  living  tissues  to  hypochlorite,  this  phenomenon  provides 
a  working  hypothesis  for  the  chemio-therapy  of  wounds 
in  spite  of  the  destructive  action  of  hypochlorite  on 
proteins. 

B.  Chloramines. — After  having  studied  the  mode  of 
action  of  hypochlorites,  Dakin  was  led  to  investigate  the 
substances  which  act  in  a  manner  almost  identical,  but 
which  are  of  greater  practical  value.  He  believed  that  the 
bactericidal  action  of  hypochlorites  took  place  by  means 
of  substances  formed  at  the  expense  of  proteins,  and 
containing  chlorine  in  combination  with  nitrogen.  Ex- 
periment showed  him  that,  when  proteins  such  as 
blood-serum,  white  of  egg,  casein,  etc.,  are  treated  by 
hypochlorites,  they  give  rise  to  products  of  a  high  anti- 
septic potency.  These  substances,  without  a  doubt,  are 
formed  iu  siiic  when  wounds  are  treated  by  hypochlorites. 
Thus,  after  the  disappearance  of  free  hypochlorite,  there 
still  remains  in  the  wound  a  substance  having  antiseptic 
power. 

Certain    aromatic    chloramines   which   form    soluble 

salts  give  encouraging  clinical  results.     The  best  of  these 

compounds  are  the  benzene-  or  the  para-toluene-sodium- 

sulphochloramines  which  have  been  described  by  Chatta- 

way. 

CH3 


SO^NaNCl  SOaNaNCl 

These   substances,  which  possess  a  very  high  anti- 

4 


so     TREATMENT   OF   INFECTED   WOUNDS 

septic  potency,  are  but  slightly  irritating,  and  can  be 
used  in  a  much  higher  degree  of  concentration  than  the 
hypochlorites.  The  solutions  in  general  use  in  our  ex- 
periments vary  from  0'2  per  cent,  to  2*0  per  cent.  The 
action  of  these  substances  is  similar  to  that  of  the  hypo- 
chlorites, but  their  antiseptic  potency  is  superior. 

I.  Bactericidal  Action. — Staphylococci  suspended  in 
water  are  killed  in  two  hours  by  benzene-sodium-sul- 
phochloramine  at  a  strength  of  i  :  500,000,  and  by 
para-toluene-sodium-sulphochloramine  at  a  strength  of 
I  :  1,000,000.  When  horse-serum  is  present,  the  strength 
necessary  becomes  i  :  1,500  to  i  :  2,500.  The  B.  pyo- 
cyaneus,  Eberth's  bacillus,  and  the  colon  bacillus  are 
slightly  more  resistant  than  staphylococci,  whilst  B. 
perfringens  and  streptococci  are  more  easily  killed. 

On  infected  wounds  chloramines  give  results  similar 
to  those  of  hypochorite  of  soda.  Their  action  on 
microbes  has  been  determined  in  the  course  of  a 
great  number  of  experiments  similar  to  those  we  have 
described  when  on  the  subject  of  hypochlorite  of  soda. 
Used  with  the  same  technique  they  sterilise  wounds. 
Their  action  on  the  tissues  has  been  studied  on  both 
sterile  and  infected  wounds,  by  comparing  the  charts  of 
sterilisation  and  the  curves  of  cicatrisation.  When  used  at 
a  strength  of  less  than  0'2  per  cent.,  they  do  not  interfere 
with  the  rapidity  of  repair.  It  has  been  observed  some- 
times, however,  that  an  aqueous  solution  of  2  per  cent, 
may  produce  lesions  of  the  connective  tissue  which 
show  themselves  by  diminution,  and  sometimes  arrest, 
of  cicatrisation. 

With  the  collaboration  of  MM.  Cohen,  Daufresne, 
and    Kenyon,  Dakin    investigated  a  certain  number  of 


THE   PRINCIPLES    OF   THE   TECHNIQUE     51 

substances  of  the  same  group,  particularly  the  chlor- 
amlnes,  in  which  the  group  NCI  is  separated  from  the 
benzene  radicle  by  the  group  S02Na  ;  the  similar 
naphthalene  derivatives  ;  the  other  similar  dicyclic 
derivatives  ;  the  chloramines  in  which  the  group  NCI 
is  directly  attached  to  the  benzene  radicle  ;  the  brom- 
amines  ;  and  finally  the  products  of  the  action  of  hypo- 
chlorites upon  different  proteid  substances.  He  found 
that  the  substances  which  contain  the  group  NCI  also 
possess  powerful  bactericidal  action.  But  the  presence 
in  their  molecule  of  more  than  one  NCI  group  does  not 
increase  their  germicidal  potency.  Molecule  for  mole- 
cule, the  germicidal  action  of  many  of  these  chloramines 
was  greater  than  that  of  hypochlorite  of  soda.  As  to 
the  substances  derived  from  proteins  under  the  influence 
of  hypochlorite  of  soda,  their  antiseptic  action  was  very 
powerful.  But  blood  serum  inhibited  their  potency,  as 
it  had  done  in  the  case  of  hypochlorite  of  soda  and  the 
aromatic  chloramines. 

While  inquiring  into  the  factors  which  control  the 
germicidal  action  of  chloramines,  Dakin  found  that 
chloramines  or  bromamines  destroy  micro-organisms  at 
a  lower  molecular  concentration  than  the  corresponding 
hypochlorites  or  hypobromites.  They  may  not,  therefore, 
be  considered  as  the  bio-chemical  equivalents  of  these 
latter  substances. 

The  germicidal  action  of  chloramines  is  due  to  the 
fact  that  the  substances  such  as  proteins,  amino-acids, 
urea,  and  ammoniacal  salts,  which  constitute  living 
organisms,  contain  nitrogen  under  a  form  which  can 
attract  the  chlorine  of  the  different  species  of  chlor- 
amines.    On  the  other  hand,  the  chlorinating  action  of 


52     TREATMENT   OF   INFECTED   WOUNDS 

chloramines  resembles  that  of  the  hypochlorites,  but 
their  antiseptic  action  is  often  much  greater.  This  fact 
may  be  attributed,  according  to  Dakin,  either  to  a  special 
obscure  action  of  the  chloramine  molecule,  or  possibly 
to  the  elective  chlorination  of  some  constituent  of  the 
cells. 

2.  The  properties  of  para-toluene-sodium-sulphochlor- 
amiiie.  —  Because  of  these  many  excellent  qualities, 
para-toluene-sodium-sulphochloramine  was  chosen  by 
Dakin  for  practical  use  in  the  sterilisation  of  wounds. 
This  substance  can  readily  be  manufactured  at  a  reason- 
able price  by  a  method  which  has  been  described  by 
Dakin.  Para-toluene-sulphochlorate,  a  by-product  in 
the  manufacture  of  saccharine,  is  the  basis.  Several 
English  houses  are  making  it,  and  sell  it  under  the  name 
of  "  Chloramine  T."  Apart  from  its  great  germicidal 
potency,  which  has  been  noticed  above,  Chloramine  T 
has  other  advantages.  It  does  not  coagulate  proteid 
matters  in  the  ordinary  treatment  of  wounds.  It  is  very 
soluble  in  water.  That  is  an  important  factor.  In  short, 
chloramines,  endowed  with  a  high  germicidal  potency, 
very  slightly  soluble  in  water,  but  which  could  be  dis- 
solved in  vaselin  or  lanolin,  would  be  w^ithout  practical 
value.  Besides,  Chloramine  T  has  the  advantage  over 
hypochlorite  of  being  very  stable.  Dakin  found  that 
the  decomposition  of  a  solution  kept  in  the  dark  for 
132  days,  was  inappreciable,  whilst  the  solution  exposed 
to  daylight  showed  such  a  slight  diminution  of  strength 
as  to  be  scarcely  noticeable.  This  stability  of  Chlor- 
amine T  is  a  great  advantage  over  Dakin's  hypochlorite 
solution,  which  decomposes  under  the  influence  of  light 
and  heat. 


THE    PRINCIPLES    OF  THE   TECHNIQUE     53 

In  the  sterilisation  of  a  wound,  the  antiseptic  plays 
a  part  comparable  to  that  of  the  scalpel  in  a  surgical 
operation.  It  is  only  an  instrument,  and  does  not  con- 
stitute a  method.  But  the  choice  of  a  good  instrument 
is  a  factor  indispensable  to  success.  Chloramines  and 
Dakin's  hypochlorite  are  admirable  instruments. 

As  Dakin's  hypochlorite  has  the  advantage  of  being 
strongly  bactericidal,  and  only  slightly  irritating  to  the 
tissues,  and  at  the  same  time  can  be  readily  manufactured 
at  a  cheap  rate,  it  would  seem  that  it  ought  to  become 
the  chosen  antiseptic  during  this  war. 

II.  Contact  of  Antiseptic  and  Micro- 
organisms. 

The  antiseptic  solution,  only  sterilising  what  it 
touches,  must  enter  into  intimate  contact  with  the 
microbes  infecting  the  wound.  This  contact  has  been 
considered  impossible  by  the  majority  of  modern 
surgeons.  Sir  Almroth  Wright  considers  that,  in  the 
wounds  inflicted  in  war,  microbes  are  found  so  deeply 
buried  in  the  irregularities  of  the  wounds,  in  the 
middle  of  necrosed  muscles  and  blood-clots,  that  it  is 
hopeless  to  try  to  reach  them  by  means  of  an  antiseptic. 
It  is  also  supposed  that,  in  suppurating  wounds,  micro- 
organisms inhabit  the  depths  of  granulation  tissue, 
muscular  interstices,  and  lymphatics,  and  that,  in  conse- 
quence, they  are  beyond  the  reach  of  substances  poured 
over  the  surfaces  of  the  wound.  It  is  certain  that  if  the 
topography  of  infection  is  such  that  the  microbes  cannot 
be  brought  into  actual  contact  with  the  antiseptic, 
chemio-therapy  of  wounds  ought  to  be  abandoned, 


54    TREATMENT   OF   INFECTED   WOUNDS 

But  the  opinion  expressed  by  Sir  Almroth  Wright 
was  based  upon  hypotheses  and  arguments,  and  not  upon 
exact  observation  of  what  takes  place  in  war- wounds. 
In  order  to  find  out  if  antiseptic  treatment  ought  or 
ought  not  to  be  appHed  to  infected  wounds,  it  is 
necessary  to  study  the  topography  of  infection  in  both 
fresh  wounds  and  suppurating  wounds,  and  to  inquire 
if  it  be  possible  to  bring  the  antiseptic  into  contact  with 
the  microbes. 


A.  Topography  of  Infection. 

1.  Fresh  Wounds. — The  topography  of  infection  was 
studied  at  first  in  freshly  inflicted  wounds,  superficial 
and  deep,  with  fracture  and  without.  Specimens  of  the 
secretions  were  taken  from  various  regions  of  the  wound, 
from  around  projectiles,  shreds  of  clothing,  splinters,  and 
from  the  surface,  then  examined  by  means  of  smears 
(p.  156)  and  cultures. 

During  the  first  few  hours  following  the  infliction 
of  the  wound,  the  smears  in  general  showed  no  microbes, 
whilst  cultures  were  positive.  The  apparent  asepsis  of 
the  smears  was  due  to  two  causes,  the  dilution  by  blood 
of  the  microbes  infecting  the  wound,  and  their  relatively 
small  number  at  this  early  period  of  the  infection.  In 
fact,  to  show  themselves  in  the  secretions,  the  organisms 
need  to  have  had  the  time  to  multiply  and  spread  them- 
selves from  the  foreign  bodies  on  to  the  surfaces  of  the 
wound. 

At  the  end  of  five  or  six  hours,  in  wounds  which  are 
not  bleeding,  rods  and  cocci  are  sometimes  found.  These 
were  localised  in  the  regions  close  to  the  foreign  bodies. 


THE   PRINCIPLES   OF   THE   TECHNIQUE     55 

Frequently  also,  no  microbe  was  visible,  though  bouillon 
in  which  shreds  of  tissue  taken  from  the  immediate  neigh- 
bourhood of  the  foreign  bodies  had  been  placed  yielded 
abundant  cultures,  aerobic  and  anaerobic  The  direct 
examination  of  foreign  bodies,  shell  splinters,  or  particles 
of  cloth,  gave  varying  results.  In  general,  no  microbes 
were  found  on  the  surface  of  projectiles,  although  in 
more  than  half  of  the  cases  they  gave  positive  cultures. 
Shreds  of  clothing,  on  the  contrary,  always  yielded  an 
abundant  microbial  flora.  Often  scrapings  of  fragments 
of  great-coat,  five  or  six  hours  after  the  infliction  of  the 
wound,  showed  some  rod-like  bodies  ;  and  nearly  always 
anaerobic  cultures  made  from  these  debris  gave  off  gas 
abundantly. 

At  the  end  of  about  twelve  hours,  bacteriological 
examination  practised  under  the  same  conditions,  showed 
microbes  more  constantly  and  in  greater  abundance.^ 
Wounds  commenced  to  react,  and  polynuclear  cells 
appeared  in  numbers  more  or  less  great. 

After  twenty-four  hours  the  topography  of  infection 
of  the  wound  had  greatly  changed,  for  the  bacterial 
harvest  was  no  longer  localised  on  the  surface,  or  around 
foreign  bodies.  The  examination  of  smears  revealed  the 
presence  of  microbes  over  almost  the  whole  extent  of 
the  wound.  At  the  same  time  a  greatly  increased 
number  of  polynuclear  cells  was  to  be  seen.  In  short, 
during  the  first  twenty-four  hours  there  may  be  witnessed, 
first,  the  multiplication  of  microbes  on  the  surface  and 
in   the    neighbourhood  of  foreign  bodies,  especially  of 

1  See  also  Policard  and  Phelip,  C.  R.  de  PAcadimie  des  Sciences,  July 
5, 1915-  Fiessinger,  La  pratique  dela  chiriirgiede guerre,  1916.  Fiessinger 
and  Montaz,  C.  R.  Sociiie  de  Biologie,  June  9,  19 16. 


56     TREATMENT   OF   INFECTED   WOUNDS 

fragments  of  clothing,  and  later  their  diffusion  over  the 
superficies  of  the  wound. 

The  modifications  of  the  bacteriological  aspect  of  a 
wound  from  the  fifth  or  sixth  hour  to  the  twenty-fourth 
hour  were  due  to  the  rapid  division  of  micro-organ- 
isms. If  it  be  supposed  that  each  microbe  divide  every 
half-hour,  it  will  give  birth  in  twelve  hours  to  more  than 
fifteen  million  other  microbes.  This  extreme  rapidity 
of  multiplication  explains  why  wounds  twenty-four  hours 
old  are  already  invaded  by  myriads  of  micro-organisms. 

Close  examination  of  a  great  number  of  wounds  has 
shown  that  these  micro-organisms  remain,  as  a  rule,  on 
the  surface  of  wounds,  and  do  not  penetrate  deeply  into 
muscular  interstices  nor  into  lymphatics.  They  invade 
blood-clots  and  tissues  without  circulation.  They  follow 
the  blood  poured  out  along  vascular  sheaths,  and  they 
may  also  bury  themselves  in  fractured  bones.  But 
usually  during  the  early  hours,  and  even  the  first  few 
days  following  the  infection  of  the  wound,  they  live 
on  the  surface  of  the  tissues  ;  that  is  to  say,  within 
reach  of  a  liquid,  if  this  liquid  be  applied  under  suitable 
conditions. 

The  existence  of  this  fact  has  been  made  plain  in  the 
course  of  experiments  made  upon  the  wounds  themselves. 
When  the  antiseptic  liquid  was  brought  into  contact  with 
the  infected  surface,  the  number  of  microbes  rapidly 
diminished,  and  at  the  end  of  a  short  time  the  wound 
became  completely  aseptic.  Wounds  of  the  surface 
could  be  sterilised  thus  in  twenty-four  hours ;  irregular 
wounds,  even  when  accompanied  by  fracture,  became 
sterile  in  five  or  six  days.  The  tissues  were  surgically 
sterile  in  their  substance  as  well  as  on  the  surface.     In 


THE    PRINCIPLES    OF   THE   TECHNIQUE     5; 

fact,  when  the  treatment  had  been  applied  from  the 
beginning,  it  was  possible  to  close  up  the  wound  by 
deep  interstitial  sutures,  without  this  being  followed  by 
rise  of  temperature.  Secondary  operations  practised  in 
cases  where  wounds  had  been  closed  after  sterilisation, 
did  not  determine  the  appearance  of  febrile  phenomena. 
When  comparing  such  results  as  these  with  what  is 
observed  always  in  the  case  of  non-sterilised  wounds,  it 
is  fair  to  conclude,  with  every  semblance  of  probability, 
that  the  microbes  have  been  destroyed  in  all  parts  of  the 
wound. 

Everything  goes  on  as  though  during  the  first  twenty- 
four  hours,  and  sometimes  during  the  early  days  follow- 
ing the  receipt  of  the  wound,  the  microbes  dwelt  on 
the  surface  of  the  wound  ;  consequently,  within  reach  of 
the  antiseptic.  However,  in  irregular  wounds  and  com- 
pound fractures  microbes  are  sometimes  found  to  be  out 
of  reach  of  the  liquid.  After  some  days  of  treatment 
the  secretions  of  certain  regions  become  aseptic,  whilst 
those  of  other  regions  still  remain  infected.  These 
regions  had  not  been  reached  by  the  liquid,  either  be- 
cause the  latter  had  not  been  introduced  deeply  into  the 
diverticula,  or  because  the  walls  were  protected  against 
the  antiseptic  by  sphacelated  tissues,  blood-clots,  or  a 
compress  soaked  in  blood.  Gauze  compresses,  blood- 
clots,  or  dead  tissues  have  a  peculiarly  harmful  effect, 
because  they  protect  the  bacteria  from  the  attack  of  the 
antiseptic. 

2.  SupptU'ating  Wounds. — During  the  period  of  suppu- 
ration, contact  between  the  microbes  and  the  antiseptic 
was,  in  general,  more  difficult  to  obtain.  The  number 
of  microbes   had   greatly   increased.     No    longer   were 


58     TREATMENT   OF   INFECTED   WOUNDS 

there  topographical  differences  in  the  volume  of  infec- 
tion, for  the  bacteria  were  found  in  almost  equal  quan- 
tities in  every  part  of  the  wound.  But,  following  the 
shape  and  character  of  the  wound,  the  microbes  were 
reached  by  the  liquid  more  or  less  easily.  In  surface 
wounds,  and  in  irregular  wounds  of  the  soft  parts,  whose 
walls  were  covered  with  granulations  and  suppurated 
abundantly,  the  antiseptic  rapidly  destroyed  the  bacteria. 
But  when  the  latter  were  protected  by  necrosed  tissue, 
tendons,  or  aponeuroses  which  were  being  eliminated, 
the  liquid  could  not  reach  them,  and  infection  persisted. 
Even  in  long-standing  wounds  the  contact  between  the 
liquid  and  the  microbes  was  so  complete  that,  in  certain 
cases,  the  latter  were  seen  to  disappear  completely  in 
forty-eight  hours. 

The  suppression  of  micro-organisms  in  secretions, 
and  the  possibilities  of  sterilising  the  surface  of  a  wound 
in  such  a  manner  that  suturing  becomes  possible,  does  not 
mean,  however,  that  all  the  microbes  have  been  brought 
into  contact  with  the  antiseptic  and  destroyed.  In  fact, 
when  by  means  of  sutures  more  or  less  deep  wounds  are 
brought  together,  which  had  suppurated  for  some  time 
before  being  sterilised,  there  is  sometimes  re-infection 
and  a  rise  of  temperature.  These  phenomena  are  not 
seen  in  wounds  which  have  been  submitted  to  sterilisa- 
tion from  the  beginning.  But  a  wound  which  is  cicatris- 
ing at  the  same  time  that  it  is  suppurating,  is  keeping  in 
its  walls  microbes  capable  of  producing  at  the  moment  of 
a  fresh  traumatism,  re-infection.  In  wounds  of  long 
standing  which  are  suppurating,  antiseptics  cannot  reach 
microbes  already  enclosed  in  granulations,  but  it  can 
affect  those  which  are  at  the  surface  of  the  wound.     As, 


THE   PRINCIPLES    OF   THE   TECHNIQUE     59 

on  the  other  hand,  living  tissues  destroy  or  encapsule 
microbes  withdrawn  from  the  antiseptic,  sterilisation 
takes  place  little  by  little. 

Therefore  it  is  important  to  sterilise  a  wound  at  a 
period  as  near  as  possible  to  the  onset  of  infection.  If 
postponed  to  a  later  period,  sterilisation  is  effected  and 
closure  by  suture  may  be  obtained  ;  but  microbes  have 
already  become  enclosed  in  the  cicatrix,  and  remain  alive 
there.  We  have  examined,  on  a  wound  more  than  six 
months  old,  a  thick  cicatrix  which  had  formed  during 
that  long  period  of  suppuration.  The  different  layers  of 
the  cicatrix  presented  a  varied  bacterial  flora.  Passing 
from  the  deepest  part  to  the  surface,  there  was  first  a 
layer  containing  Welch's  bacillus,  next  a  sterile  layer, 
then  a  stratum  containing  small  rod-like  bodies,  lastly  a 
layer  of  various  cocci.  In  wounds  of  long  standing,  the 
topography  of  infection  is  therefore  such  that  the  anti- 
septic cannot  reach  the  microbes  in  every  part  in  which 
they  are  found.  But,  on  the  other  hand,  the  microbes 
are  enclosed  or  encapsuled  in  the  tissues,  and  are  not  in 
a  condition  to  work  harm  until  a  new  traumatism  sets 
them  free. 

From  the  practical  point  of  view,  in  the  suppurating 
wounds  of  soft  parts,  contact  between  microbes  and  anti- 
septic sufficient  to  assure  surgical  sterilisation  is  possible 
of  attainment.  In  deep  wounds  with  pus  burrowing 
along  muscular  interstices,  where  contact  between  anti- 
septic and  microbe  cannot  be  realised,  results  are  less 
favourable.  When  suppurating  wounds  are  accom- 
panied by  fractures,  or  the  osseous  fissures  described 
by   Policard,^    along    which    the    micro-organisms    are 

^  See  also  Bowlby,  "  Wounds  in  War,"  The  Lancet^  191 5>  PP-  1388,  1389. 


6o     TREATMENT   OF   INFECTED    WOUNDS 

propagated,  it  becomes  impossible  to  make  the  liquid 
penetrate  into  all  the  infected  places.  Similarly,  when 
osteo-myelitis  has  declared  itself,  or  when  splinters  have 
been  left  in  the  tissues,  the  conditions  are  the  same. 
Microbes  establish  themselves  in  the  sequestra  at  such  a 
depth  that  the  antiseptic  cannot  penetrate  to  them. 
They  are  protected  by  their  situation,  at  the  same  time 
against  the  chemical  agent  and  against  the  polynuclear 
cells  coming  from  normal  tissues.  This  is  the  reason 
why  the  infection  is  so  extremely  tenacious,  when  bony 
lesions  or  necrosed  splinters  persist  at  the  bottom  of 
irregular  wounds. 

This  brief  examination  of  the  topography  of  infection 
shows  that  in  the  majority  of  cases  it  is  possible  to  obtain 
intimate  contact  between  antiseptic  and  microbe.  Suit- 
able preparation  of  the  wound  for  the  penetration  of  the 
germicide  substance,  and  distribution  of  this  substance 
over  the  whole  of  the  affected  surface,  will  enable  this 
contact  to  be  realised.  If,  up  to  the  present,  we  have 
not  succeeded  in  chemically  sterilising  wounds,  it  is,  in 
part,  because  we  have  neglected  to  prepare  them  in  such 
a  manner  that  the  antiseptic  substance  may  reach  every 
point  where  microbes  exist. 

B.  Preparation  of  the  Wound  for  the  Penetration  of 
the  Antiseptic. 

Most  important  in  the  preparation  of  the  wound  is 
the  mechanical  cleansing  of  the  infected  regions.  Free 
incisions  in  the  soft  parts  allow  this  cleansing  to  take 
place  even  in  the  case  of  irregular  torn  wounds,  accom- 
panied  by  fracture.      It    is  well    known  that  shreds  of 


THE   PRINCIPLES   OF   THE   TECHNIQUE     6i 

clothing,  projectiles,  splinters  lying  free,  blood-clots  and 
necrosed  tissues  serve  as  shelters  for  microbes  and  protect 
them  from  the  antiseptic.  In  consequence,  every  foreign 
body  should  be  most  carefully  sought  for  and  removed. 
Debris  of  clothing  are  the  principal  source  of  infection, 
and  the  antiseptic  generally  cannot  penetrate  them. 
Necrosed  tissues  are  the  favourite  haunt  of  gas  infection. 
Therefore  they  must  be  removed.  Ever  since  the  begin- 
ning of  the  war,  Depage  and  the  surgeons  of  his  school 
have  made  a  systematic  resection  of  all  tissues,  skin, 
aponeuroses  or  muscles  which  were  likely  to  mortify. 
This  practice  is  excellent  and  ought  to  become  general. 
All  blood-clots  are  removed,  and,  to  prevent  their  re- 
occurrence, careful  ha^mostasis  of  the  whole  of  the 
wound  is  practised.  The  surface  of  bony  cavities  in 
which  projectiles  are  lodged,  is  scraped,  and  resected  if 
needful.  Furthermore,  it  is  well  to  remember  that  com- 
presses placed  in  wounds  efficiently  protect  microbes 
against  antiseptics.  Therefore  a  wound  should  never 
be  left  plugged  with  tampons  or  compresses.  If  an 
open  wound  is  desired,  tubes  of  large  calibre  perforated 
with  many  wide  holes  are  used. 

Incisions  are  made  in  such  a  manner  that  the  diver- 
ticula of  the  wound  are  laid  open  as  freely  as  possible. 
The  liquid  should  penetrate  everywhere,  and  remain  in 
contact  with  the  infected  area  as  long  as  needful.  As 
gravity  plays  an  important  part  in  the  distribution  of  a 
liquid,  those  wounds  which  can  be  filled  up  like  a  cup 
are  the  most  favourably  qualified  for  sterilisation.  That 
is  the  reason  why  wounds  on  the  anterior  surface  of 
limbs  are  preferred  to  dependent  counter-openings. 
Liquid    is   thus    retained   in    the   wound    and    its   walls 


62     TREATMENT   OF   INFECTED   WOUNDS 

bathed  more  completely.  Very  large  incisions  need 
not  be  objected  to,  because  they  allow  the  topography 
of  the  wound  to  be  studied  and  diverticula  dealt  with. 

Once  the  wound  has  been  thus  freely  laid  open  and 
all  foreign  bodies  removed,  the  best  possible  conditions 
for  contact  between  the  liquid  and  the  surfaces  of  the 
wound  are  obtained.  It  only  remains  to  make  arrange- 
ments for  the  application  of  the  antiseptic  to  the  whole 
of  the  infected  surface. 


C.  Application  of  the  Antiseptic. 

It  is  indispensable  to  place  the  liquid  in  direct  contact 
with  the  tissues  in  the  deepest  regions  of  the  wound. 
Distribution  of  a  liquid  over  the  whole  extent  of  an 
irregular  surface  is  difficult  to  accomplish. 

The  simplest  method,  which  at  once  occurs  to  every 
one,  is  to  use  absorbent  gauze  or  other  fabric,  or  strands 
of  cotton-wick,  conducting  by  capillary  action  the  liquid 
from  an  external  reservoir  over  the  whole  surface  of  the 
wound.  This  arrangement  has  been  adopted  by  Sir 
Almroth  Wright  in  his  dressings  of  hypertonic  saline 
solution.  At  the  outset  of  our  researches  on  the  steri- 
lisation of  wounds  we  employed  a  similar  method.  Layers 
of  absorbent  tissue  were  applied  to  the  surface  of  the 
wound,  a  rubber  tube  led  the  liquid  to  the  tissue  to 
which  was  entrusted  equal  distribution  to  all  parts  of 
the  wound.  Experience  was  not  slow  in  making  clear 
to  us  that  procedures  based  on  this  principle  were 
incapable  of  producing  efficient  contact  of  the  antiseptic 
with  the  surfaces  of  the  wound.  In  fact,  at  the  end  of 
a  few  hours  the  deepest  part  of  the  conducting  tissue 


THE   PRINCIPLES    OF  THE  TECHNIQUE    63 

became  impregnated  with  plasma  or  pus,  and  imperme- 
able to  the  antiseptic  liquid.  On  casual  examination, 
the  apparatus  appeared  to  be  working  well,  but  the 
liquid  went  into  the  tissue  without  moistening  the  raw 
surfaces.  This  method  of  conducting  the  liquid  was 
abandoned  entirely.  It  has  only  been  retained  to  dis- 
tribute liquid  on  the  surface  of  a  rubber  tube  pierced 
with  small  holes.  These  tubes  covered  with  tissue  are 
sometimes  used  during  the  first  few  hours  following  the 
infliction  of  a  wound,  because  at  this  period  secretion  is 
slight.  In  all  other  cases  we  use  absorbent  tissue  com- 
presses, which  by  a  special  arrangement  cause  the  liquid 
to  flow  between  themselves  and  the  wound. 

The  procedure  which  has  been  adopted  consists  in 
distributing  the  liquid  to  all  parts  of  the  wound  by 
means  of  rubber  tubes,  utilising  the  force  of  gravity  of 
the  liquid.  The  disposal  of  these  tubes  varies  with  the 
shape  and  situation  of  the  wound.  In  wounds  which 
have  only  a  single  opening  so  situated  that  they  can  be 
filled  up  like  a  cup,  permanent  contact  between  the  anti- 
septic and  the  surfaces  is  assured  by  introducing  a  rubber 
tube  to  the  bottom  of  the  cavity  (Fig.  14).  If  the 
patient  reclines  in  a  suitable  position,  the  wound  remains 
full  of  antiseptic  liquid.  But  in  dealing  with  surface 
wounds  (Fig.  15) — large,  irregular  wounds,  and  those 
with  several  wide  openings  (Fig.  16) — it  becomes  more 
difficult  to  distribute  the  liquid  over  the  whole  surface. 
The  most  practical  method  consists  in  allowing  small 
rubber  tubes  perforated  with  minute  holes  to  He  on  the 
tissues.  The  holes  number  fifty  to  each  tube,  and  have 
a  diameter  of  about  0*5  millimetre.  When  these  tubes 
are  charged  with  liquid  under  pressure,  the  surface  of 


64     TREATMENT   OF    INFECTED   WOUNDS 


the  wound  is  moistened  by  the  fluid  which  issues  from 
all  the  orifices.  This  procedure  has  been  adopted,  in 
the  first  place,  because  it  is  successful,  and  next,  because 
it  can  be  carried  out  by  means  of  articles  readily  obtain- 
able commercially.  The  tubes  should  be  tied  up  at  one 
end  and  the  perforations  made  with  an  ordinary  punch. 

But  this   manner  of  distribution    is    far  from   ideal, 
because,  the  holes  being  too  large  and  not  sufficiently 


Fig.  14. — Wound  with  superior  opening 
which  can  be  filled  like  a  cup. 


Fig.  15. — Surface  wound  receiving  liquid 
from  a  tube  perforated  by  small  holes. 


Fig.  16. — Irregular  wound  with  several 
perforated  tubes  in  its  diverticula. 


numerous,  the  liquid  spurts  out  too  profusely  over  a 
space  too  limited.  So  it  is  not  made  the  best  use  of. 
Probably  a  tiny  hose,  pierced  with  a  great  number  of 
microscopic  holes,  or  rather  rubber  membranes,  whence 
the  antiseptic  could  ooze  out,  would  bring  about  more 
intimate  relations  between  liquid  and  microbes.  A 
totally  different  arrangement  might  be  conceived,  by 
which  the  liquid  could  be  distributed  over  the  surface  of 


THE    PRINCIPLES   OF   THE   TECHNIQUE     65 

the  wound  without  using  tubes  at  all.  If  the  antiseptic 
were  incorporated  with  a  substance  which  had  the  pro- 
perty of  melting  very  slowly  in  contact  with  the  tissues, 
and  which  at  the  same  time  could  be  moulded  to  fit  all 
the  irregularities  of  the  wound,  a  more  perfect  distribu- 
tion of  the  antiseptic  would  be  attained. 

III.  Maintaining  the  Concentration  of  the 

Antiseptic 

The  second  essential  principle  is  the  keeping  the 
fluid  on  the  surface  of  the  tissues  at  a  constant  degree  of 
concentration.  Up  to  the  present,  this  principle  has 
been  completely  ignored.  As  a  rule,  antiseptics  are 
applied  to  wounds  by  means  of  absorbent  gauze,  and  the 
liquid  renewed  once  or  twice  in  the  twenty- four  hours. 
It  is  certain,  however,  that,  under  these  conditions,  the 
bactericidal  power  of  the  substances  employed  rapidly 
vanishes.  In  fact,  if  a  compress  soaked  in  Dakin's  solu- 
tion 0"5  per  cent,  be  applied  to  the  surface  of  a  wound, 
the  result  obtained  is  almost  nil,  because  the  concentra- 
tion of  the  solution  lessens  very  quickly,  under  the  in- 
fluence of  dilution  by  the  secretions  of  the  wound,  and 
the  combination  of  hypochlorite  of  soda  with  the  proteins 
of  pus,  of  the  tissues,  and  of  blood.  In  a  word,  the 
degree  of  concentration  of  an  antiseptic  applied  accord- 
ing to  the  usual  surgical  method  at  once  becomes  so 
feeble  that  no  result  can  be  hoped  for.  The  only  way 
to  maintain  at  the  needful  strength,  on  the  surface  of  a 
wound,  a  solution  which  is  constantly  being  diluted  and 
destroyed,  is  to  keep  on  renewing  it,  unceasingly.  For 
this   reason    we    have    used    instillation,    continuous    or 

s 


66    TREATMENT   OF   INFECTED   WOUNDS 

intermittent.  The  best  method  consists  in  allowing  a 
current  of  the  antiseptic  liquid  to  flow  very  slowly  over 
the  whole  surface  of  the  wound.  In  the  case  of  small 
wounds,  and  of  those  which  can  be  filled  with  liquid  like 
a  cup,  this  is  readily  done.  The  antiseptic,  supplied 
drop  by  drop,  is  slowly  renewed,  in  contact  with  the 
tissues.  When  it  escapes  from  the  wound,  it  is  absorbed 
by  the  dressing,  and  evaporates  without  wetting  the 
patient.  But  when  the  wound  is  of  large  extent,  and 
presents  several  openings,  a  considerable  quantity  of 
liquid  would  be  needed  to  keep  the  whole  raw  surface 
continually  moist.  The  amount  which  would  escape 
from  the  wound  would  be  too  great  to  be  absorbed  by 
the  dressing.  One  has  to  revert  to  the  old  process  of 
continuous  irrigation,  which  is  complicated,  and  distress- 
ing to  the  patient. 

On  the  other  hand,  experience  has  shown  that  if  the 
liquid  be  applied  over  the  surface  of  the  wound  every 
hour  or  every  two  hours,  sterilisation  is  attained.  This 
intermittent  instillation  is  easy  to  apply.  It  is  the  pro- 
cedure we  are  at  present  employing.  It  is  far  from  being 
perfect,  but  it  allows  of  the  frequent  contact  of  the 
surfaces  of  the  wound  with  the  antiseptic  at  a  known 
degree  of  concentration.  Better  arrangements  for  keep- 
ing up  both  supply  and  strength  of  the  antiseptic  will 
doubtless  be  found.  For  example,  if  the  liquid  were  to 
issue  from  numerous  microscopic  apertures  in  tubes  in- 
serted in  all  the  cavities  of  the  wound,  the  quantity 
needed  would  be  smaller,  and  yet  every  part  of  the 
wound  would  be  bathed  incessantly  by  the  antiseptic  at 
the  desired  strength. 

The  degree  of  concentration  of  the  antiseptic  has  been 


THE   PRINCIPLES    OF   THE   TECHNIQUE     6^ 

determined  empirically.  It  is  found  that  Dakin's  solu- 
tion, containing  0*45  to  0*5  per  cent  of  hypochlorite  of 
soda,  applied  under  the  conditions  just  described,  does 
no  harm  to  tissues  and  sterilises  wounds. 


IV.  Duration  of  the  Application  of  the 

Antiseptic 

An  essential  point  of  the  method  is  the  prolonged  appli- 
cation of  the  antiseptic.  This  principle  seems  to  have  been 
neglected  as  much  as  the  preceding.  Although  experi- 
ments in  vitro  have  shown  that  microbes,  to  be  destroyed, 
must  be  immersed  in  the  antiseptic  solution  during  a 
long  enough  period,  yet  people  persisted  in  believing 
that,  under  the  much  more  unfavourable  conditions  of 
the  clinic,  sterilisation  of  a  wound  could  be  obtained  by 
brief  contact  between  bactericidal  substance  and  microbes. 
That  is  why  so  many  surgeons  still  remain  loyal  to  the 
rite  of  washing  over  a  wound  with  an  antiseptic  liquid. 
They  imagine  that  if  a  liquid  has  flowed  over  the  surface 
of  a  wound  for  four  or  five  minutes,  often  much  less,  that 
wound  will  become  sterile.  It  is  certain,  however,  that 
to  obtain  any  action  the  antiseptic  must  remain  on  the 
wound  for  a  much  longer  period. 

A.  Experiments  showing  the  Necessity  for  Prolonged 
Contact. — In  the  following  clinical  experiments  it  was 
sought  to  discover  what  should  be  the  length  of  time  for 
the  application  of  the  hypochlorite. 

In  the  first  place,  the  influence  of  hypochlorite  applied 
as  is  usual  in  a  wet  dressing  was  examined.  Upon 
surface  wounds,  whose  bacteriological  condition  was 
known,  compresses  were  placed  soaked  in  a  0*5  per  cent. 


68     TREATMENT   OF   INFECTED    WOUNDS 

solution  of  hypochlorite.  The  next  day  the  number 
of  microbes  had  not  undergone  any  appreciable  change. 
Gauze  "  wicks  "  soaked  in  hypochlorite  were  also  intro- 
duced into  deep  wounds.  At  the  end  of  twenty-four 
hours,  the  surface  of  the  compresses  yielded  a  large 
number  of  microbes. 

The  insufficiency  of  the  technique  usually  employed 
was  thus  demonstrated.  Next,  the  length  of  time 
during  which  hypochlorite  was  present  in  the  wounds 
was  lengthened  by  soaking  the  dressing  with  antiseptic 
three  times  a  day.  In  most  cases  the  "  smears  "  showed 
a  marked  lessening  in  the  number  of  microbes  ;  but  the 
wounds  more  deeply  infected  showed  no  change.  On 
one  small  wound  dressed  three  times  a  day  with  hypo- 
chlorite, the  number  of  microbes  did  not  diminish.  At 
the  end  of  a  week  of  this  useless  treatment,  every  hour 
a  small  quantity  of  hypochlorite  was  injected  over  the 
surface  of  the  wound,  under  the  compresses.  All  the 
microbes  disappeared  (Fig.  17). 

A  large  number  of  similar  experiments  showed  that, 
in  surface  wounds,  the  infection  did  not  resist  instilla- 
tions of  hypochlorite  every  two  hours  during  one  or  two 
days.  In  deep  wounds,  diminution  in  the  number  of 
microbes  came  about  more  slowly,  even  under  the 
influence  of  frequent  instillation  of  hypochlorite.  Daily 
examination  of  the  "  smears,"  made  from  the  discharges 
from  different  regions  of  wounds  of  the  soft  parts,  more 
or  less  irregular,  showed  that  microbes  often  took  four 
or  five  days  to  disappear.  In  severe  lacerations  of  the 
soft  parts,  or  in  compound  fractures,  the  application  of 
the  hypochlorite  had  to  be  continued  usually  eight,  ten, 
or  fifteen  days  before  sterilisation  was  achieved. 


THE    PRINCIPLES    OF   THE   TECHNIQUE     6g 

In  wounds  complicated  by  splintered  fractures  some- 
times it  was  impossible  to  get  complete  sterilisation. 
Generally  the  persistence  of  infection  was  due  to  the 
presence  of  a  foreign  body,  projectile,  splinter  or  shred 
of  clothing.  When  the  foreign  body  was  removed, 
sterilisation  came  about.  Disinfection  of  deep  wounds 
always  takes  longer  than  that  of  surface  wounds.     With 


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Frc  17. — Necessity  for  prolonged  contact  between  the  antiseptic  and  the 
wound.  Highly  infected  level  wound  treated  up  to  Nov.  26th  by  applica- 
tions of  hypochlorite  three  times  a  day.  No  diminution  in  the  number  of 
microbes.  Nov.  26th,  Dakin's  hypochlorite  was  applied  every  hour. 
Sterilisation  was  attained  Nov.  29th.     (co  denotes  infinity.  —  Travs.) 


the  technique  now  in  use,  compound  fractures  are  some- 
times disinfected  in  five  or  six  days.  As  a  general  rule, 
.sterilisation  requires  ten,  fifteen,  or  twenty  days,  or  even 
more,  if  it  is  a  question  of  a  compound  fracture  of  the 
thigh. 

B.  Relation  between  the  Dimensions  of  a  Wound  and 
the   Time  required    for  Sterilisation. — It  will    be   well  to 


70     TREATMENT   OF   INFECTED   WOUNDS 

inquire  why  the  duration  of  application  of  the  antiseptic 
has  to  be  longer  for  compound  fractures  with  large 
wounds,  than  for  surface  wounds. 

We  have  often  seen  surface  wounds  yielding  many 
microbes  become  sterilised  in  forty-eight  hours.  The 
tardiness  of  sterilisation  in  irregular  wounds  appears  to 
be  due  to  the  presence  of  diverticula  into  which  the 
liquid  does  not  penetrate,  and  where  microbes  swarm, 
or  to  the  presence  of  sphacelated  tissues  which  shield 
the  microbes  from  the  attack  of  the  antiseptic.  How- 
ever, in  surface  wounds,  with  sphacelated  tissue,  sterilisa- 
tion is  brought  about  more  quickly  than  in  large  and 
irregular  wounds.  Therefore  it  is  probable  that  imper- 
fection of  technique  alone  renders  necessary  a  prolonged 
application  of  the  antiseptic.  There  is  not,  in  fact,  any 
theoretic  reason  why  a  large  and  irregular  wound  should 
sterilise  more  slowly  than  a  small  wound  with  even  walls. 
But  it  is  much  more  difficult  to  make  the  liquid  penetrate 
all  the  irregularities  of  a  deep  wound  than  it  is  to  bring 
it  into  contact  with  the  entire  surface  of  a  smooth  one. 

The  duration  of  the  application  of  hypochlorite  in 
deep  wounds  will  lessen  when  it  becomes  possible  to 
apply  continuously  the  antiseptic  to  the  entire  surface 
of  the  wound.  Our  technique  is  still  too  clumsy,  and 
the  methods  of  distributing  the  liquid  in  use  to-day  do 
not  succeed  in  placing  every  portion  of  a  large  wound 
simultaneously  under  the  influence  of  the  bactericidal 
substance.  It  is  quite  probable  that  different  portions 
of  an  extensive  wound  are  sterilised  successively,  for  the 
bacteriological  examination  shows  that  after  the  lapse  of 
several  days  certain  regions  of  a  wound  are  sterile,  whilst 
others    still    continue    to    harbour    microbes.     Besides, 


THE   PRINCIPLES   OF   THE   TECHNIQUE     71 

rapidity  of  sterilisation  increases  to  a  certain  extent 
with  the  quantity  of  liquid  employed,  that  is  to  say,  it 
depends  on  the  extent  of  the  surface  of  the  wound  which 
is  acted  on  by  the  liquid.  It  is  permissible  to  believe 
that  improvements  in  technique  will  lessen  the  period 
during  which  antiseptic  instillations  will  need  to  be 
employed,  but  it  is  unlikely  that  this  period  will  be  cut 
down  to  less  than  twenty- four  hours. 


V.  Knowledge  of  the  Bacteriological 
Conditions  of  the  Wound 

The  bactericidal  potency  of  the  chloramines  and 
of  hypochlorite  is  such  that  every  wound  should  respond 
to  the  treatment  by  a  diminution  in  the  number  of 
microbes  and  by  their  final  disappearance.  Therefore 
it  is  important  to  ascertain  if  the  bacteriological  condition 
is  being  modified  in  a  progressive  manner.  In  fact, 
when  that  condition  remains  stationary,  it  may  be  con- 
cluded that  contact  between  antiseptic  and  microbes  is 
not  completely  established,  and  that  the  technique  needs 
alteration. 

Clinical  observation  alone  does  not  enable  us  to 
follow  the  evolution  of  wound  infection.  It  gives  only 
the  probabilities.  When  a  patient  has  ceased  to  have 
pyrexia,  when  the  wound  is  of  a  healthy  red,  when  its 
margins  are  supple  and  when  suppuration  has  dis- 
appeared, then  it  is  fair  to  assume  that  the  wound  is 
nearly  aseptic.  But  investigation  has  taught  us  that 
wounds  looked  upon  as  aseptic  are  often  highly  infected, 
and  that  it  is  never  safe  to  trust  the  favourable  appear- 
ance of  the  tissues  as  evidence   that   they  are   sterile. 


72     TREATMENT   OF    INFECTED    WOUNDS 

Besides,  it  often  happens  that  wounds  treated  by 
chloramines  have  a  slightly  greyish  look,  and  are 
covered  with  purulent  secretion.  They  have  the  appear- 
ance of  infected  wounds.  However,  these  wounds  may 
be  sutured  without  the  least  rise  of  temperature  follow- 
ing. In  this  case  only  bacteriological  examination  can 
demonstrate  to  the  surgeon  that  the  pus  which  covers 
the  granulations  is  aseptic. 

It  is  impossible,  therefore,  to  ascertain  the  results 
of  treatment  with  sufficient  precision,  without  the  con- 
stant aid  of  the  microscope.  Using  the  simple  method 
which  will  be  described  later,  bacteriological  examination 
of  a  large  number  of  wounds  may  be  made  every  day. 
M.  Gaultier  ^  has  shown  that,  even  in  dressing-stations 
{ambulances,  Fr.)  at  the  front,  it  is  possible  to  make  use 
of  the  microscope.  That  examination  gives  warning 
of  the  existence  of  errors  of  technique  as  soon  as  they 
appear,  and  so  enables  the  loss  of  time  to  be  avoided 
which  is  the  usual  consequence.  It  points  out  the 
moment  when  the  wound  has  become  surgically  sterile 
and  can  be  sutured. 

To  sum  up,  knowledge  of  the  bacteriological  con- 
dition of  the  wound  is  an  indispensable  part  of  the 
technique  of  sterilisation,  and  it  alone  can  give  to  the 
latter  the  necessary  precision. 

'  Gaultier,  Paris  Mhiical,  Ji'b'j  I916. 


CHAPTER    II 

TFXHNTOUE    OF  THE    MANUFACTURE    OF    DAKIN'S 

SOLUTION 

Hypochlorite  of  soda  was  discovered  by  Berthollet  in 
1788,  and  its  antiseptic  properties  have  been  known 
for  a  long  time.  Labarraqiie  gained  great  renown  by 
embalming,  by  the  aid  of  his  liquor,  the  corpse  of 
Louis  XVIII.,  which  was  so  extremely  decomposed  that 
no  one  could  come  near  it.  But  neither  Labarraque's 
solution  nor  eau  de  Javel  can  be  used  with  safety  in 
surgery.  One  of  the  essential  conditions  of  the  sterilisa- 
tion of  wounds  is,  as  is  well  known,  the  employment  of 
a  substance  which,  in  a  given  degree  of  concentration, 
can  be  applied  for  a  long  period  to  wounds  without 
irritating  them.  This  is  the  reason  why  it  is  impossible 
to  use  commercial  hypochlorites,  whose  content  of  hypo- 
chlorite is  extremely  variable  and  which  contain  free 
alkali.  The  proportion  of  alkali  contained  in  eau  de 
Javel  and  Labarraque's  liquor  is  great  enough  to  pro- 
duce solution  of  the  skin,  if  the  contact  be  sufficiently 
prolonged. 

I.  Dakin's  Technique 

That  is  why  Dakin  sought  the  means  of  obtaining 
a   solution   deprived   of   free    caustic   alkali,  and   whose 

73 


74     TREATMENT    OF   INFECTED    WOUNDS 

content  of  hypochlorite  must  not  vary  beyond  the  Hmits 
of  0"45  and  0*50  per  cent.  Later  experiments  by 
Daufresne  showed  that  below  0*45  per  cent,  the  solution 
is  insufficiently  active,  whilst  above  0*5  per  cent,  it  is 
irritating.  At  the  time  of  his  communication  to  the 
Academic  des  Sciences,  Dakin  gave  a  method  of  prepara- 
tion of  this  solution  which  enabled  it  to  be  made  with 
the  simplest  appliances,  without  chemical  knowledge. 

"  140  grammes  of  anhydrous  carbonate  of  soda,  or 
400  grammes  of  the  crystallised  salt,  are  dissolved  in 
10  litres  of  ordinary  water,  and  200  grammes  of  chloride 
of  lime  of  good  quality  are  added  to  it.  The  mixture  is 
well  shaken,  and  at  the  end  of  half  an  hour  the  clear 
liquid  is  siphoned  off  and  filtered  through  cotton.  To 
the  filtrate  are  added  40  grammes  of  boric  acid,  and  the 
solution  thus  obtained  may  be  used  at  once  ;  it  does  not 
colour  phtalein  in  suspension  in  water."  ^ 

This  very  simple  mode  of  preparation  was  easy  to 
execute,  a  great  advantage  for  hospitals  at  the  front. 
But  experience  in  its  use  has  brought  to  light  several 
inconveniences,  which  have  been  studied  by  Daufresne. 
One  of  the  products  used  in  its  preparation,  chloride  of 
lime,  being  of  very  variable  composition,  its  content  of 
active  chlorine  might  vary  from  the  normal  to  double  the 
amount.  Under  the  influence  of  humidity  it  forms  com- 
pact masses,  which,  when  agitated  with  the  solution  of 
carbonate  of  soda,  are  incompletely  broken  up,  and  only 
yield  a  portion  of  their  hypochlorite.  These  are  the 
reasons  why  defective  solutions  have  sometimes  been 
obtained  while  following  conscientiously  the  procedure 
ju^t  described. 

^  Dakin,  Presse  Medicale^  loc.  cit. 


PREPARATION    OF   DAKIN'S   SOLUTION     75 

On  the  other  hand,  Daufresne  was  led  to  attribute 
certain  irritation  phenomena  to  the  boric  acid  employed 
to  neutralise  the  solution.  In  fact,  without  being  able  to 
give  an  exact  account  of  the  chemical  reactions  which 
enter  into  the  change,  every  time  the  quantity  of  boric 
acid  used  to  arrive  at  non-coloration  in  the  phtalein 
test  exceeds  4  grammes  per  litre,  the  solution  becomes 
unstable  and  painful. 

Besides,  the  solutions  of  hypochlorite  prepared  with 
boric  acid,  even  in  correct  quantity,  keep  badly. 


II.  Dakin's  Solution  prepared  by  Daufresne's 

Method 

Having  on  several  occasions  observed  similar  solutions, 
Daufresne  sought  a  remedy  for  these  inconveniences  by 
a  more  accurate  mode  of  preparation  which  would  give 
constant  results.  After  numerous  trials  he  decided  on 
the  following  process. 

A.  Preparation  of  Dakin's  Solution  by  Daufresne's  Pro- 
cess.— I.  To  prepare  10  Htres  of  solution  weigh  out 
exactly : 

Chloride   of  lime   (having   25    per  cent. 

active  chlorine)  .         .         .         .184  grammes 

Carbonate  of  soda,  anhydrous  (carbonate 

de  sonde,  Solvay,  Fr.)  .  .  .92  „ 
(Or  carbonate  of  soda,  crystals  .  .  262)  „ 
Bicarbonate  of  soda  ,         .         .         ,       ^6         ^, 

2.  Place  in  a  12-litre  flask  the  200  grammes  of  chloride 
of  lime  and  5  litres  of  tap- water  ;  shake  vigorously  two 
or  three  times,  and  leave  it  all  night. 


•]6    TREATMENT   OF    INFECTED    WOUNDS 

3.  Dissolve  in  5  litres  of  cold  water  the  carbonate 
and  bicarbonate  of  soda. 

4.  Pour  the  solution  of  soda  salts  into  the  flask 
containing  the  suspended  chloride  of  lime,  shake  well 
during  one  minute,  and  place  aside  at  rest  to  allow  the 
carbonate  of  lime  to  settle. 

5.  At  the  end  of  half  an  hour  siphon  off  the  clear 
liquid  and  filter  it  with  a  double  paper  to  obtain  a 
perfectly  clear  product,  which  should  be  kept  in  the  cold 
and  away  from  the  light. 

The  antiseptic  solution  is  then  ready  for  surgical  use. 
It  should  contain  0*475  P^^  cent,  of  hypochlorite  of  soda, 
with  small  quantities  of  neutral  salts  of  soda.  It  is 
isotonic  to  blood-serum.^ 

B.  Chloride  of  Lime  and  its  Titration. —  i.  The  chloride 
of  lime  of  commerce  is  obtained  by  the  action  of  gaseous 
chlorine  on  powdered  slaked  lime.  It  presents  great 
variations  in  composition  ;  notably  in  its  content  of  active 
chlorine.  Its  chemical  constitution,  in  .spite  of  the  numer- 
ous discussions  of  which  it  has  been  the  subject,  is  not 
yet  established  in  any  satisfactory  manner.  Whatever  it 
may  be,  we  know  that  under  the  solvent  action  of  water 
it  yields  three  substances,  hypochlorite  and  chloride  of 
calcium  and  small  quantities  of  lime,  the  residue  being 
made  up  of  excess  of  lime,  partially  carbonated. 

The  action  of  water  on  chloride  of  lime  is  not  instan- 
taneous ;  the  product  often  contains  lumps,  whence  the 
hypochlorite  does  not  readily  diffuse.  The  following 
experiment  of  Daufresne^  is  instructive. 

'  These  solutions  have  a  freezing-point  very  slightly  higher  tban  that 
of  blood-serum  :  A  =  —  0'6o  to  —  0*65. 
-  Daufresne,  Presse  MedicaU,  1916. 


PREPARATION    OF    DAKIN'S   SOLUTION     ^7 

10  grammes  of  chloride  of  lime  giving  on  titration 
28*25  per  cent,  of  active  chlorine  are  introduced  into  a  flask 
with  1000  c.c.  of  distilled  water.  The  whole  is  shaken 
vigorously  for  two  minutes  and  the  solution  titrated. 

Similar  titrations  are  made  from  time  to  time. 


Titration  after  con 

tact  of 

the  solution  (in 'CI  %). 

i-  hour.     1      1  hour. 

2  hours. 
0-259 

6  hours. 

12  hours. 

0*089 

o"i76 

0'206 

0-281 

0-282 

The  solution  is  only  complete  after  several  hours  of 
maceration,  and  for  this  reason  we  have  prescribed  in  our 
technique  prolonged  contact  between  the  chloride  of 
lime  and  the  water. 

The  proportion  of  184  grammes  of  chloride  of  lime  to 
10  litres  of  water  indicated  in  these  two  formulae  corre- 
sponds to  a  product  of  good  average  quality  (25  per 
cent,  of  active  chlorine),  but  samples  of  very  different 
degrees  of  richness  are  frequently  met  with.  We  had 
occasion  to  examine  a  small  number  of  samples  whose 
active  chlorine  content  varied  from  20*45  P^i*  cent,  to 
3 5 "9  ps^  cent.  There  is  no  reason  why  the  Service  de 
Sante  should  not,  when  supplying  the  quantity  demanded, 
place  on  it  a  label  indicating  the  percentage  of  chlorine 
{degres  anglais^  Fr.).  Or  the  toxicologist  of  the  division 
to  which  the  hospital  belongs  could  readily  ^\s[^  this 
information. 

2.  Titration  of  chloride  of  lime.  Because  of  these 
variations  in  commercial  chloride  of  lime,  it  is  indis- 
pensable to  know  the  quantity  of  active  chlorine  contained 
in   the  chloride  of  lime  with  which  one  is  working,   in 


78     TREATMENT   OF   INFECTED   WOUNDS 

order  to  use  an  amount  calculated  exactly,  according  to 
its  titration. 

The  estimation  is  made  in  the  following  manner  by 
Daufresne  :  Weigh  out  an  average  sample  of  20  grammes, 
stir  it  up  in  a  litre  of  water  as  perfectly  as  possible,  and 
allow  it  to  stand  some  hours.  Measure  off  lO  c.c.  of  the 
clear  liquid,  add  to  it  20  c.c.  of  a  10  per  cent,  solution  of 
iodide,  2  c.c.  of  acetic  acid  or  hydrochloric  acid,  then  to 
the  mixture  add  drop  by  drop  a  decinormal  solution  of 
hyposulphite  of  soda  (2*48  per  cent),  up  to  decolora- 
tion. The  number  n  of  c.c.  of  hyposulphite  employed, 
multiplied  by  1,775,  will  give  the  weight  N  of  active 
chlorine  contained  in  100  grammes  of  the  chloride  of 
lime. 

This  estimation  must  be  carried  out  for  each  con- 
signment received.  Should  the  obtained  result  differ 
from  the  average  figure  of  25  per  cent.,  the  proportion 
of  the  three  substances  entering  into  the  preparation 
must  be  reduced  or  augmented.  This  is  readily  found 
by  multiplying  each  of  the  three  sets  of  figures, 
184,  92,  "J 6^  by  the  factor  25/N,  in  which  N  represents 
the  weight  of  active  chlorine  per  cent,  in  the  chloride 
of  lime. 

The  following  table  drawn  up  by  Daufresne  is 
intended  to  avoid  this  calculation,  and  to  give  directly, 
according  to  the  amount  of  active  chlorine  contained  in 
the  chloride  of  lime,  the  amounts  needed  to  obtain  auto- 
matically a  correct  solution. 


PREPARATION    OF   DAKIN'S   SOLUTION     79 


Quantities  to  be  used  to  obtain  lo  litres  of  solution  of 

Tit 

ation  of  chloride  of  lime 

(CI  %). 

(Knglish  degrees.) 

hypochlorite  of  o"475  %. 

Chloride  of 

Carbonate  of 

Bicarbonate  of 

lime. 

soda,  anhydrous. 

soda. 

grms. 

grms. 

grms. 

20 

230 

115 

96 

21 

220 

1 10 

92 

22 

210 

105 

88 

23 

200 

100 

84 

24 

192 

96 

80 

25 

184 

92 

76 

26 

177 

89 

72 

27 

170 

85 

70 

28 

164 

82 

68 

29 

159 

80 

66 

30 

154 

77 

64 

31 

.     148 

74 

62 

32 

144 

72 

60 

33 

140 

70 

59 

34 

135 

68 

57 

35 

132 

66 

55 

36 

128 

64 

53 

37 

124 

62 

52 

The  determination  of  the  quantity  of  soluble  calcium 
in  the  chloride  of  lime  would  have  a  certain  importance 
if  one  were  not  obliged,  in  order  to  obtain  a  product 
having  some  degree  of  stability,  to  use  an  amount  of 
carbonate  of  soda  far  above  that  indicated  by  the 
theory.  In  fact,  a  solution  prepared  by  the  interaction 
of  chloride  of  lime  and  salts  of  soda  in  theoretic  quan- 
tities loses  the  whole  of  its  hypochlorite  in  from  15  to 
20  days. 

C,  Salts  of  Soda. — It  is  more  convenient  to  use  dry 
carbonate  of  soda  {carbonate  de  sonde,  Solway,  Fr.)  which 
is  to  be  preferred  to  the  other  commercial  salts  because 
of  its  being  anhydrous,  pulverulent,  and  free  from  caustic 
alkali. 

When  obliged  to  use  the  hydrated  salt  (crystals),  the 


So     TREATMENT    OF    INFECTED    WOUNDS 

quantity  needful  will  be  285  grammes  for  100  of  the  dry    I 
salt.  " 

Bicarbonate  of  soda  is  readily  obtainable.  It  is 
always  anhydrous.  The  solution  should  be  made  in  the 
cold,  because  it  commences  to  break  up  towards  50^  C. 

When  the  solution  of  carbonate  and  bicarbonate  of 
soda  is  poured  into  the  maceration  of  chloride  of  lime, 
an  abundant  precipitate  of  carbonate  of  lime  appears, 
result  of  the  double  decomposition  which  takes  place 
between  the  soluble  constituents  of  the  chloride  of  lime 
and  the  soda  salts. 

The  two  principal  reactions  are  : — 

(C10)2Ca  +  C03Na2  =  COsCa  -f  2C10Na 
CaCli  +  COaNa.,  =  CO^Ca  +  2NaCl 

but  the  chloride  of  lime  always  contains  a  residue  of  non- 
chlorinated  lime,  which  may  amount  to  20  per  cent,  of 
the  total  weight,  and  of  which  a  small  quantity  dissolves 
in  water  during  the  course  of  preparation.  This  lime  in 
its  turn  intervenes  in  a  secondary  reaction,  when  the 
formula  is  only  concerned  with  the  carbonate  of  soda  : 

Ca(0H)2  4-  COaNaa  =  COaCa  +  2NaOH 

setting  free  a  small  quantity  of  alkali,  to  which  the 
classic  Labarraque's  liquor  owes  its  causticity.  In  Dakin's 
process,  this  alkali  is  neutralised  by  an  excess  of  boric 
acid. 

In  Daufresne's  process  no  caustic  soda  is  formed  ; 
the  liquor  contains,  in  fact,  a  certain  quantity  of  carbonic 
acid,  feebly  combined  (that  of  the  bicarbonate  of  soda), 
which  attaches  itself  to  the  lime  as  soon  as  the  two 
solutions  come  into  contact. 


PREPARATION    OF   DAKIN'S    SOLUTION     Si 

It  is  difficult  to  demonstrate  with  certainty  what  is 
the  intimate  mechanism  of  fixation  of  the  lime,  but  it 
may  be  imagined.  As  a  matter  of  fact,  it  is  for  the 
carbonic  acid,  amongst  all  the  substances  present,  that 
lime  possesses  the  greatest  affinity.  Henceforward,  the 
harmful  part  played  by  the  lime  is  suppressed,  and  the 
secondary  reaction  we  have  indicated  is  changed  into  one 
perfectly  inoffensive : 

Ca(0H)2  4-  2C0,NaH  =  CO.Ca  -f-  CO.Naa  +  2lL,0 

D.  Titration  of  the  Sohition  of  Hypochlorite.^ — Measure 
lO  c.c.  of  the  solution,  add  20  c.c.  of  ten  percent,  solution 
of  iodide  of  potassium,  2  c.c.  of  acetic  acid,  then  drop  by 
drop  a  decinormal  solution  of  hyposulphite  up  to  decolora- 
tion. The  number  of  c.c.  used,  multiplied  by  0-03725, 
will  give  the  weight  of  hypochlorite  of  soda  contained  in 
100  c.c.  of  solution. 

In  the  first  stage  of  the  determination,  hypochlorite 
displaces  the  iodine  of  the  iodide  of  potassium  according 
to  the  equation 

ClONa  +  2KI  +  H2O  =  I2  +  2KOH  +  NaCl 

which  is  only  complete  in  the  presence  of  a  quantity  of 
acid  sufficient  to  saturate  completely  the  liberated  potash. 
The  operation  returns  finally  to  an  estimation  of  iodine 
by  hyposulphite  of  soda  : 

I2  +  2S20aNa2  =  2NaI  +  SiOi^Naii 

Examining  the  various  reactions,  we  see  that  a  single 
molecule  of  hypochlorite  decomposes  two  molecules  of 
iodide    of  potassium  with    liberation    of  two   atoms    of 

*  See  Daufresne,  Uc.  cit. 

6 


82     TREATMENT   OF   INFECTED   WOUNDS 

iodine,  and  that  each  atom  of  iodine  transforms  a 
molecule  of  hyposulphite  into  tetra-thionate  of  soda  ; 
thus : 

I  mol.  SsOsNa  ->  i  atom  of  I  ->  I  mol.  ClONa 
248  "  37-25 

On  the  contrary,  if  as  in  the  estimation  of  chloride  of 
lime  the  result  had  to  be  determined  in  active  chlorine 
(decolorising  chlorine),  it  would  have  been  necessary  to 
take  into  account  that  one  atom  of  chlorine  only  displaces 
one  atom  of  iodine  : 

2CI  -f-  2KI  =  21  +  2KCI  and 

2I  +  2S203Na2  =  2NaI  +  S406Na2 

and 

I  mol.  S20oNa2  ->  i  atom  of  I  ->  i  atom  of  CI 
248  35*5 

The  equations  (in  the  case  of  a  sample  of  10  c.c.) 
which  give  the  activity  of  a  solution  of  hypochlorite,  will 
be  different,  according  as  the  result  is  expressed,  either 
directly  in  hypochlorite,  or  indirectly  in  the  quantity  of 
chlorine  of  equivalent  activity. 

Hypochlorite  per  cent.        .         .     N  X  0*03725 
Active  chlorine  per  cent.    .         .     N  x  0*0355 

It  is  necessary  to  insist  on  this  point,  because  the 
same  coefficient  of  activity  is  sometimes  wrongly  attri- 
buted to  the  hypochlorite  as  to  the  chlorine.  Now,  this 
error  of  interpretation  might  have,  from  the  point  of  view 
with  which  we  are  dealing  at  present,  the  serious  conse- 
quence of  leading  one  to  consider  as  correct  a  solution 


PREPARATION    OF   DAKIN'S   SOLUTION     83 

which  only  contains  0*25   per  cent,  of  hypochlorite  of 
soda. 


III.  Keeping  Qualities  of  the  Solution 

Solutions  of  hypochlorite  do  not  keep  indefinitely, 
they  change  very  slowly  in  the  dark,  much  more  quickly 
in  the  light.  Daufresne  studied  the  influence  of  light  in 
the  following  manner. 

Portions  of  the  same  solution  of  known  strength  were 
placed  in  two  flasks,  one  flask  was  left  on  the  laboratory 
table  exposed  to  diffused  light,  while  the  other  was  kept 
in  a  cupboard.  He  ascertained  that  the  activity  of  the 
solution  sheltered  from  the  light  had  not  sensibly  varied, 
whilst  the  first  had  lost  about  20  per  cent,  of  its 
hypochlorite. 


Solution    kept    in    tbe^l 
light,  titration ,     .     ./ 
Solution    kept    in    the)^ 


dark,  titration 


After 


o  day.      7  days.     15  days.    21  days.    30  days 


0*505 
0-505 


0*497 
0-505 


0-452 
0-502 


0-411 
0-500 


Loss  in 

one 
moutli. 


0-380       247  % 


0*497 


I '4 


0/ 


When  the  mass  of  liquid  is  considerable,  the  altera- 
tion is  extremely  slow.  Daufresne  kept  a  solution  of 
hypochlorite  of  0*502  per  cent,  of  ClONa  in  a  wicker- 
covered  carboy  of  black  glass,  25  litres,  without  any 
special  precautions  as  regards  light.  At  the  end  of  $\ 
months  the  titration  gave  —0*493  per  cent,  of  ClONa,  a 
loss  practically  negligible. 

What  becomes  of  the  hypochlorite  .?  One  cannot 
say   with   certainty.      By   analogy   with    what    happens 


84     TREATMENT   OE   INFECTED   WOUNDS 

under  the  influence  of  heat,  it  is  thought  that  the  hypo- 
chlorite tends  towards  its  two  stable  forms,  chloride  and 
chlorate  of  sodium  : 

4C10Na  =  sNaCl  +  ClOaNa  +  O 

Obviously,  this  reaction  implies  a  release  of  oxygen, 
which  is  sometimes  lacking.  Besides,  it  does  not 
explain  all  the  facts  observed.  It  is  sufficient  to 
remember  that,  in  practice,  it  is  better  to  keep  the 
solutions  away  from  the  light,  and  still  more  important, 
to  renew  them  as  frequently  as  possible,  every  ten  or 
fifteen  days  at  least. 


IV.    Comparison    of     Dakin's    Solution    with 
Labarraque's  Liquor  and  Commercial  Eau 

DE  JAVEL 

The  mistake  is  often  made  of  identifying  Labarraque's 
liquor  and  even  commercial  eau  de  Javel  with  Dakin's 
solution.  But  Daufresne  has  shown  by  simple  methods, 
that,  from  the  biological  as  well  as  the  chemical  point 
of  view,  these  three  solutions  behave  in  very  different 
ways. 

Amongst  the  reactions  which  may  be  cited  for  this 
purpose,  two  are  particularly  characteristic  ;  the  phenol- 
phtalein  reaction  and  the  effect  upon  skin.  In  these 
experiments  the  three  solutions  are  brought  to  a  con- 
venient strength  of  {O  gr.  50  %,  Fr.)  of  hypochlorite 
of  soda.  The  action  upon  skin  has  already  been 
described  (p.  22).  We  shall  here  give  only  the  action 
upon  phenol-phtalein. 

If  20  c.c.  of  the  solution  to  be  examined  are  poured 


PREPARATION    OP^   DAKIN'S   SOLUTION     85 

into  a  beaker  and  on  the  surface  are  placed  a  few 
centigrammes  of  phenol-phtalein  in  powder,  it  is  seen 
that  :— 

1st.  Eau  de  Javel  and  Labarraque's  liquor  immedi- 
ately colour  the  particles  of  phenol-phtalein  an  intense 
red,  and  the  slightest  shaking  will  suffice  to  communicate 
to  the  whole  of  the  liquid  a  bright  red  colour,  which 
slowly  disappears  under  the  decolorising  action  of  the 
hypochlorite. 

2nd.  Dakin's  solution,  under  the  same  conditions, 
does  not  give  any  colour  to  the  particles  of  phtalein,  and 
it  is  only  after  vigorous  and  prolonged  shaking  that  the 
liquid  becomes  of  a  faint  rose  tint. 

Then,  if  one  seeks  the  amount  of  alkalinity  which  a 
solution  must  possess  in  order  to  give  so  much  colour  to 
powdered  phtalein,  it  is  found  that  only  solutions  con- 
taining at  least  0'2  per  cent,  of  caustic  alkali  will  give  to 
the  phtalein  test  a  similar  degree  of  colour.  Carbonate 
of  soda  only  gives  an  almost  imperceptible  tinge  to  the 
particles  of  phtalein,  and  a  rosy  tint  to  the  liquid :  that 
same  solution  gives  no  colour  if  it  only  contain  2"0  per 
cent,  carbonate  of  soda. 

Therefore  Labarraque's  liquor  and  eau  de  Javel  each 
contain  a  small  quantity'  of  caustic  soda,  revealed  by  the 
phenol-phtalein  test,  and  which  might  readily  be  foreseen 
after  examination  of  their  mode  of  preparation. 

In  fact,  Labarraque's  liquor  and  many  samples  of 
commercial  eau  de  Javel  are  obtained  by  double  decom- 
position of  a  solution  of  chloride  of  lime  and  a  solution 
of  carbonate  of  soda.  All  the  constituents  of  chloride 
of  lime  (hypochlorite  of  calcium,  chloride  of  calcium, 
slaked  lime)  are  able  to  react  upon  carbonate  of  soda. 


86    TREATMENT   OF   INFECTED   WOUNDS 

giving  respectively  hypochlorite  of  soda,  chloride  of 
sodium  and  caustic  soda.  This  caustic  alkali,  which 
constitutes  the  irritating  element  most  to  be  dreaded 
in  hypochlorite  solution,  certainly  exists  in  the  earlier 
stages  of  preparation  as  given  by  Dakin  ;  but  later  it 
is  neutralised  by  excess  of  boric  acid.  We  have  seen 
why  it  is  not  formed  in  the  process  described  by 
Daufresne. 


V.  Causes  of  Error 

When  the  rules  laid  down  by  Dakin  and  by  Daufresne 
for  the  manufacture  of  hypochlorite  of  soda  are  followed, 
the  solution  fulfils  all  the  desired  conditions.  Experience 
has  shown  us,  however,  that  in  the  various  hospitals 
where  Dakin's  solution  is  said  to  have  been  in  use,  they 
often  employ  under  this  name  various  mixtures,  more  or 
less  dangerous.  These  defective  solutions,  which  do 
irritate  tissues  and  do  not  sterilise  wounds,  are  the  result 
of  more  or  less  clumsy  faults  in  technique. 

1st.  The  worst  error  consists  in  attributing  to  eau  de 
Javel  or  Labarraque's  liquor  mixed  with  a  certain  pro- 
portion of  boric  acid,  the  properties  possessed  by  Dakin's 
solution.  A  certain  number  of  surgeons  are  not  afraid 
to  use  similar  solutions.  Thus  in  one  large  hospital  they 
are  using,  under  the  label  of  "  Dakin's  Solution,"  a 
mixture  of  Labarraque's  liquor  and  40  per  cent,  boric 
solution.  It  is  perfectly  certain  that  solutions  of  which 
one  does  not  know  the  content,  either  of  the  alkali  or  the 
hypochlorite  of  soda,  are  useless  or  dangerous. 

2nd.  Other  errors  crop  up  when  hypochlorite  of  soda 
solution  is  prepared  according  to  Dakin's  method,  but 


PREPARATION    OF   DAKIN'S    SOLUTION     ^7 

by  means  of  chloride  of  lime  of  which  the  content  of 
active  chlorine  is  not  known.  The  result  is  that  the  pro- 
portions of  carbonate  and  bicarbonate  of  soda  are  no 
longer  exact,  and  the  product  obtained  is  no  longer 
Dakin's  solution.  Therefore  it  is  indispensable  to  verify 
always  the  titration  of  chloride  of  lime  ;  and,  the  solution 
once  obtained,  to  titrate  the  quantity  of  hypochlorite 
which  it  contains  and  to  apply  the  phtalein  test  according 
to  Dakin's  technique.  Hence,  errors  in  the  mode  of 
preparation  result  in  solutions  which  are  irritating 
because  they  contain  too  much  alkali  or  too  much 
hypochlorite  of  soda  ;  or  which  fail  to  sterilise  wounds 
because  the  amount  of  hypochlorite  of  soda  is  too  small, 
or  which  do  not  keep  well  because  they  are  charged  with 
too  much  boric  acid. 

3rd.  Mistakes  may  be  made  in  the  way  in  which  the 
solution  is  kept.  Should  hypochlorite  of  soda  be  kept 
in  small  quantities  exposed  to  light  and  heat,  the  strength 
of  the  solution  rapidly  lessens.  We  have  seen  in  use  in 
a  hospital,  a  solution  whose  hypochlorite  content  had 
diminished  to  nearly  0*05 .  These  mistakes  are  readily 
avoided  by  using  fresh  solutions,  or  rather  by  taking 
pains  to  keep  the  solution  in  darkness  and  in  a  cool 
place.  It  is  prudent  to  make  titrations  of  the  hypo- 
chlorite of  soda  from  time  to  time. 

4th.  Errors  in  the  strength  of  the  solution  also  occur. 
In  certain  hospitals  we  have  seen  a  solution  used  whose 
hypochlorite  content  was  correct,  but  whose  strength 
was  reduced  by  addition  of  water.  Solutions  thus 
obtained  have  a  bactericidal  potency  far  too  feeble,  and 
they  must  not  be  used.  Since,  as  the  result  of  numerous 
experiments,   it   has  been    determined   that   a   solution 


8H     TREATMENT    OF    INFECTED   WOUNDS 

varying  from  0*45  to  050  per  cent,  has  no  irritating 
action  on  the  tissues  when  used  under  the  conditions 
previously  described,  Dakin's  solution  pure  and  simple 
should  be  employed.  There  is  no  danger  when  it  is 
accurately  prepared.  It  is  important  to  ascertain  that 
the  details  of  the  method  previously  described  have 
been  followed  to  the  letter,  if  it  is  desired  to  obtain 
Dakin's  solution  with  its  characteristic  properties. 
Furthermore,  the  procedure  for  sterilisation  has  been 
calculated  with  a  view  to  the  application  of  a  liquid 
possessing  the  strength  and  qualities  of  Dakin's  solution, 
so  that  any  alteration  in  the  solution  robs  the  method 
of  its  precision  and  its  efficacy. 


CHAPTER    III 

THE    TECHNIQUE    OF    THE    STERILISATION    OF 
WOUNDS — MECHANICAL    CLEANSING 

The  first  stage  of  treatment  consists  in  preparing  for 
the  penetration  of  the  liquid  by  surgical  interference  and 
by  mechanical  cleaning  of  the  wound.  This  intervention 
is  indispensable,  in  order  that  intimate  contact  between 
antiseptic  and  microbe  may  be  established.  It  differs 
only  by  some  details  from  the  methods  in  general  use 
to-day. 

I.  The  Time  for  Mechanical  Cleansing 

Surgical  interference  and  mechanical  cleaning-up  of  a 
wound  are  practised  as  soon  as  possible  after  the  infliction 
of  the  injury.  The  time  for  interference  is  of  the  greatest 
moment,  for  the  surgical  proceeding  has  a  gravity  vary- 
ing according  to  the  stage  of  infection  in  which  it  takes 
place. 

I.  Every  infected  wound  at  first  goes  through  a 
stage  which  might  be  termed  pre-inflammatory,  during 
which  the  various  local  symptoms  are  very  slight  or  non- 
existent. Muscles  and  cellular  tissue  preserve  their 
normal  appearance.  So  far  there  is  neither  sv/elling  of 
the    tissues    nor  the    reddened    tracks  of  lymphangitis. 

89 


90    TREATMENT   OF   INFECTED   WOUNDS 

The  temperature  is  normal  or  rises  slowly.  This  stage 
usually  lasts  from  twelve  to  twenty-four  hours,  and  is 
sometimes  prolonged  to  forty-eight  hours.  During  this 
pre-inflammatory  period  free  incisions  and  search  for 
foreign  bodies  or  projectiles  present  no  danger.  This  is 
the  period  of  the  infection,  during  which  all  surgical 
interference  should  be  carried  out  as  far  as  possible. 
It  is  with  wound-infection  as  with  appendicitis.  Inter- 
ference during  the  first  twenty-four  hours  carries  with 
it  little  danger,  and  nearly  always  yields  excellent 
results. 

2.  At  the  end  of  a  period  varying  from  twelve  to 
forty-eight  hours,  and  occasionally  longer,  the  inflamma- 
tory stage  begins.  The  temperature  goes  up,  and  marked 
symptoms  of  infection  appear  on  the  surface  of  the 
wound.  These  infectious  complications  present  them- 
selves under  two  aspects,  gangrenous  or  phlegmonous. 
In  the  gas  form  of  infection  multiple  incisions  with, 
thorough  opening-up  do  not  aggravate  the  patient's 
condition,  and  as  a  rule  allow  the  progress  of  infection  to 
be  checked.  It  is  not  the  same  with  infections  of  the 
phlegmonous  type,  which  are  due  often  to  the  presence 
of  streptococci. 

Every  one  knows  the  appearance  of  the  phlegmon- 
ous wounds.  Neither  gangrene  nor  gas  is  present,  but 
the  tissues  are  infiltrated  and  painful.  Serum  pours 
from  the  wound.  Sometimes  there  is  lymphangitis, 
and  the  glands  of  a  limb  near  the  trunk  are  swollen 
and  tender  on  pressure.  This  stage  may  last  several 
days,  and  sometimes  several  weeks.  When  the  patient 
is  in  this  condition,  the  surgical  measures  which  might 
have    been    practised    had    the    operation    taken    place 


TECHNIQUE   OF   STERILISATION        91 

during  the  first  twenty-four  hours  are  no  longer  indi- 
cated. Free  incisions  and  prolonged  search  for  foreign 
bodies  or  spHnters  might  set  up  septicaemia,  or  at  least 
aggravate  phenomena  both  local  and  general.  During 
this  anxious  period  one  has  to  be  contented  with 
no  more  than  is  absolutely  necessary.  To  operate  at 
this  moment  is  to  make  the  patient  run  the  same  risks 
as  a  case  of  acute  appendicitis  which  is  operated  on 
after  three  or  four  days. 

3.  When  the  stage  of  acute  infection  is  past,  and 
suppuration  has  commenced,  the  search  for  projectiles, 
shreds  of  clothing,  splinters  may  be  undertaken  with 
far  less  danger.  But  osteo-myelitis  in  some  cases  has 
made  its  appearance,  and  wound-cleansing  cannot  be  as 
efficacious  as  at  the  outset. 

Upon  the  whole,  the  most  favourable  time  for  any 
operation  called  for  by  reason  of  anatomical  lesions  is 
the  pre- inflammatory  stage.  If  the  general  condition 
permit,  now  is  the  time  to  carry  out  without  danger  any 
necessary  surgical  interference.  It  is  the  reason  why 
the  wounded  man  should  be  got  as  quickly  as  possible 
to  the  hospital,  where  complete  surgical  treatment  can 
be  carried  out. 


II.  Technique   of    the    Mechanical   Cleansing 

OF  THE  Wound 

A.  Pre-infiammatory  Period. — As  soon  as  the  patient 
arrives  at  the  hospital  {ambidance^  Fr.),  he  is  warmed 
and  cleaned  up.  If  needed,  treatment  for  shock  is 
carried  out.  Then  surgical  treatment  of  the  wounds  is 
immediately  proceeded  with. 


92     TREATMENT   OF   INFECTED   WOUNDS 

I.  Clinical  and  Radiological  Examination. — {a)  Notes 
of  the  wounds  having  been  taken,  their  relations  to  the 
various  organs  of  the  damaged  region  are  examined.  The 
opening  of  the  wound  should  be  neatly  trimmed  according 
to  its  requirements.  Fascia  is  split  or  torn  by  the  pro- 
jectile. Muscles  present  as  a  hernia  or  retract  to  leave  a 
gaping  hole.  Lastly,  blood  issues  from  the  wound,  either 
alone  or  mingled  with  the  fat  coming  from  a  fracture, 
cerebro-spinal  fluid,  brain  matter,  urine  or  faeces.  Inspec- 
tion of  the  orifice  often  yields  valuable  indications  of 
underlying  injuries.  The  surrounding  skin  may  be  red 
and  tense.  Sometimes  a  furrow  ending  at  the  orifice 
gives  the  direction  of  the  projectile.  At  another  part  of 
the  limb  a  cutaneous  bruise  may  be  seen  without  solution 
of  continuity  of  the  skin.  Frequently  the  projectile  is 
found  at  this  spot.  The  whole  region  in  which  the 
wound  is  situate  is  more  or  less  swollen.  Occasionally  it 
is  puffy  around  the  opening. 

In  certain  cases  the  whole  segment  of  the  damaged 
limb  is  swollen  and  hard.  Very  rarely  is  pulsation  felt 
or  a  murmur  heard.  This  swelling  is  due  nearly 
always  to  haemorrhagic  infiltration  of  the  inter-muscular 
cellular  tissue,  particularly  of  the  posterior  aspect  of  the 
calf  or  thigh.  It  is  a  lesion  which  it  is  important  to  bear 
in  mind.  In  fact,  serious  infections  often  occur  in  these 
layers  of  connective  tissue,  whose  blood-infiltration  may 
be  widely  extended  and  form  an  ideal  culture-ground. 
Just  as  often,  instead  of  swelling  we  find  a  localised 
depression  between  the  two  orifices.  This  depression 
corresponds  to  a  sub-cutaneous  section  of  the  muscles  by 
a  projectile  which  has  traversed  the  limb  seton-fashion. 
It   is  well  to   have   this    information    before    operating, 


TECHNIQUE    OF   STERILISATION         93 

because  it  determines  the  nature  of  the  surgical  inter- 
ference. Because,  if  muscles  are  severed,  we  may  unite 
the  two  openings  of  the  seton  by  an  incision  at  right 
angles  to  the  long  axis  of  the  limb  ;  whereas,  if  the 
muscles  are  sound,  the  two  orifices  should  be  opened 
up  by  incisions  parallel  to  the  long  axis  of  the  limb. 

Pain  may  prove  a  useful  guide.  Often  a  tender  spot 
points  out  the  site  of  the  projectile.  The  bony  skeleton 
must  be  examined,  not  only  to  recognise  a  complete 
fracture,  almost  always  easy  to  identify,  but  also  to  ensure 
that  the  splinters  of  an  incomplete  fracture  should  not 
escape  notice. 

The  circulation  and  innervation  of  the  distal  portion 
of  the  limb  are  equally  subjected  to  careful  investiga- 
tion. 

{b)  It  is  indispensable  that  the  casualty  clearing 
station  {ambulance,  Fr.)  should  possess  a  radiological 
installation  to  allow  of  exact  localisation  of  projectiles. 
We  shall  not  here  go  into  details  as  to  the  most  useful 
method  of  procedure.  Simple  radioscopy  enables  us,  if 
we  move  certain  muscles  with  the  finger,  or  obtain 
voluntary  contraction,  to  fix  the  site  of  projectiles.  It 
is  a  quick  and  practical  way  of  localising  multiple 
projectiles. 

To  summarise,  both  a  general  examination  and  a 
minute  local  examination  should  be  made,  as  much  to 
decide  the  actual  possibility  of  surgical  interference,  as 
to  fix  its  duration  and  extent.  Equipped  with  this 
information,  we  may  proceed  as  quickly  as  possible  to 
the  mechanical  cleansing  of  the  wounds. 

2.  Anaesthesia. — General  anaesthesia  should  always  be 
employed.     Ether  should  be  used  ;  chloroform  as  rarely 


94    TREATMENT   OF   INFECTED   WOUNDS 

as  possible.     In  certain  cases  spinal  anaesthesia  may  be 
used. 

3.  Opening-up  and  cleaning  a  Wound  of  the  Soft  Parts. 
— The  skin  is  sterilised  by  tincture  of  iodine.  As  the 
cutaneous  apertures  of  entrance  and  exit  of  projectiles 
are  too  small  to  allow  of  an  examination  of  the  course 
taken  by  the  foreign  body,  they  must  be  enlarged.  The 
extent  of  opening-up  depends  upon  the  depth  of  the 
track  of  the  missile.  The  eye  must  be  able  to  surve}' 
the  whole  extent  of  the  wound,  especially  when  fracture 
exists.  The  incisions,  therefore,  are  as  long  as  may  be 
needful,  and  parallel  with  the  long  axis  of  the  limb  or 
the  fibres  of  the  underlying  muscles.  As  a  matter  of 
fact,  the  track  of  the  bullet  nearly  always  goes  through 
the  muscles  we  are  intending  to  clean,  and  which  must 
be  cut  as  little  as  possible.  The  muscular  track,  there- 
fore, is  laid  open  by  an  incision  as  wide  as  the  skin- 
opening.  We  do  not  insist  upon  the  necessity  for 
respecting  vessels  and  nerves.  In  the  case  of  a  blind 
track,  if  it  does  not  suffice  to  lay  open  the  orifice,  a 
counter- opening  should  be  made,  which  will  permit 
examination  of  the  whole  extent  of  the  wound. 

In  wounds  of  the  "  seton "  type,  the  two  orifices 
are  laid  open  separately,  parallel  with  the  long  axis  of 
the  limb,  so  that  the  entire  track  is  plainly  visible.  If 
this  seton-type  of  wound  is  superficial,  it  is  sometimes 
advisable  to  lay  it  open  from  one  orifice  to  the  other. 
Should  muscles  be  severed  by  the  projectile  it  is  pre- 
ferable to  open  up  the  wound  completely,  in  order  to 
clean  it  the  more  thoroughly. 

There  is  no  call  for  hesitation  in  making  very  free 
incisions,  because  they  can  be  brought  together  again 


i 


TECHNIQUE   OF   STERILISATION        95 

after  a  few  days.  Extensive  opening-up  of  soft  parts 
nearly  always  yields  earlier  closing. 

{a)  The  bruised  portions  of  the  track  are  carefully 
excised.  To  Depage  and  the  surgeons  of  his  school  is 
due  the  merit  of  having  shown  how  useful  it  is  to 
resect  almost  the  whole  of  the  area  of  the  wound.  The 
skin  which  surrounds  the  opening,  the  sub-cutaneous 
cellular  tissue,  the  superficial  fascia,  and  above  all,  the 
muscles  in  the  first  third  of  the  track,  are  almost  always 
riddled  with  threads  of  wool  or  cotton  from  the  clothine 

o 

These  shreds  are  embedded  in  the  tissues.  No  amount  of 
mopping  or  scrubbing  is  capable  of  getting  rid  of  them. 
They  can  only  be  removed  by  removing  the  tissues 
themselves.  This  line  of  conduct  is  all  the  more  justified 
by  the  fact  that  muscular  or  cellular  tissue  thus  im- 
pregnated with  tiny  foreign  bodies  is  certainly  destined 
to  necrosis  and  elimination. 

The  mechanical  cleansing  of  a  wound,  therefore, 
commences  by  removal  of  the  skin  which  adjoins  the 
orifices,  of  the  sub-cutaneous  cellular  tissue  fouled  by 
fragments  of  clothing  and  often  infiltrated  with  blood, 
and  of  the  muscular  track  encrusted  with  foreign  bodies. 
The  muscular  wall  is  resected  to  a  thickness  of  about 
two  millimetres  over  almost  the  whole  extent  of  the 
wound.  This  cleaning  with  a  cutting  instrument  is 
much  to  be  preferred  to  manceuvres  which  injure 
tissues  without  cleansing  them.  It  is  no  use  sponging 
a  track  with  a  gauze  swab,  introduced  by  one  orifice, 
pushed  to  and  fro,  and  then  removed  by  the  other  open- 
ing. This  kind  of  cleansing  is  always  ineffective  and 
harmful,  for  it  inoculates  healthy  tissues  throughout  the 
whole  extent  of  the  wound,  and  produces  lesions  which 


96     TREATMENT    OF    INFECTED   WOUNDS 

may  be  followed  by  necrosis.  Indispensable  manipula- 
tions, such  as  the  repeated  pressure  of  gauze  com- 
presses on  a  wound-surface  to  check  haemorrhagic 
oozing,  or  the  use  of  metallic  retractors,  have  already 
bruised  the  tissues.  Rough  handling,  likely  to  aggravate 
pre-existing  injuries  and  increase  tissue-infection,  must 
be  carefully  avoided. 

{b)  Haemostasis. — In  the  course  of  the  operation,  the 
organs,  vessels,  and  nerves  in  the  neighbourhood  are 
examined  and  haemostasis  of  the  track  completel}' 
established.  When  injury  to  a  large  vessel  is  found 
in  the  track  of  a  projectile,  it  is  most  necessary  to  see 
that  adjoining  cellular  interspaces  have  not  been  opened 
up  and  infiltrated  with  extravasated  blood.  This  lesion 
is  common  on  the  posterior  aspect  of  the  thigh  and  calf. 
In  fact,  in  the  sheath  of  the  sciatic  nerve,  under  the 
biceps,  semi-membranosus,  and  semi-tendinosus,  haema- 
tomata  are  sometimes  found,  infiltrated  in  the  connective 
tissue  which  separates  the  different  muscles.  The  same 
thing  occurs  in  the  calf,  near  the  soleus,  gastro-cnemius 
and  flexors.  There  must  be  no  hesitation  about  laying 
open  these  spaces  from  one  end  to  the  other,  for  infection 
spreads  there  with  the  greatest  readiness,  and  may 
become  of  extremely  grave  character.  Incisions  are 
made  in  such  a  way  as  not  to  endanger  the  circulation 
of  the  part. 

(c)  Searchfoi'  and  Extraction  of  Pi'ojectiles  and  Shreds 
of  Clothing. — The  difficulties  of  searching  for  projectiles 
are  due  to  the  dimensions,  sometimes  extremely  small, 
of  the  foreign  bodies,  to  the  thickness  of  the  muscular 
stratum  in  which  they  are  embedded,  and  to  the  irregu- 
larity of  the  course  of  the  projectile  through  the  tissues. 


TFXHNIOUE   OF   STERILISATION         97 

When  a  wound  is  cleansed  some  hours  after  infliction, 
and  the  foreign  body  is  as  large  as  a  small  nut,  it  is 
generally  easy  to  find  it.  The  muscles  which  surround 
the  track  seem  struck  by  paralysis.  Eye  and  finger 
follow  the  route  of  the  missile  all  the  more  readily  when 
radiography  has  indicated  the  direction  of  the  track. 
One  always  tries  to  arrive  at  the  projectile  by  means 
of  the  track,  because  it  has  to  be  followed  and  the  whole 
wound  cleaned.  However,  if  the  track  is  too  long,  it  is 
easy  to  make  a  counter-opening  in  the  immediate  neigh- 
bourhood of  the  projectile.  This  counter-opening  not 
only  allows  the  projectile  to  be  extracted,  but  also  the 
inspection  of  the  wound  to  be  completed,  and  this  part 
of  the  track  to  be  resected.  The  various  apparatus  for 
registration,  and  Bergonie's  electrovibrator  should  be 
made  use  of.  Sometimes  the  minute  fragments  of  shell 
are  very  difficult  to  locate.  In  fact,  the  openings  they 
leave  when  traversing  fascia  are  very  small.  Often  these 
may  be  identified,  but  directly  afterwards  the  track 
through  muscular  fibre  is  lost.  Hirtz'  or  Contremoulin's 
compass  may  prove  of  use.  But  when  the  shell-frag- 
ments are  numerous  and  close  together,  the  multiplicity 
of  points  registered  on  the  skin  is  bewildering.  Then 
is  the  time  to  call  in  the  aid  of  the  telephone  vibrator 
of  M.  de  la  Baume-Pluvinel.  This  apparatus  enables  us 
to  find  the  tiniest  fragments. 

It  is  much  more  important  to  remove  shreds  of  cloth- 
ing than  projectiles.  As  a  rule,  the  missile  is  wrapped  up 
in  the  fabric  it  has  carried  along  with  it,  but  sometimes 
it  has  only  pushed  the  cloth  in  front.  By  the  aid  of  dis- 
secting forceps,  every  particle  of  fabric  which  is  found 
on  the  surface  of  the  wound  is  removed  with  minute  care. 

7 


98     TREATMENT   OF   INFECTED   WOUNDS 

The  toilet  is  completed  by  washing  both  wound  and 
adjoining  skin  with  neutral  oleate  of  soda. 

(d)  Drainage. — Drainage  of  the  wound  should  be 
liberally  arranged,  but  by  a  procedure  different  from 
what  is  usually  employed.  Counter-openings  are  not 
made  at  dependent  points.  In  fact,  the  antiseptic  solu- 
tion must  come  into  contact  with  the  entire  surface  of 
the  tissues,  and  consequently  fill  the  wound.  The  liquid 
must  not  be  allowed  to  escape  through  the  bottom.  We 
shall  even  see,  later  on,  that  when  a  wound  is  being 
drained  naturally  through  a  dependent  opening,  the 
inferior  orifice  should  be  plugged  by  a  tampon.  There- 
fore we  have  to  be  contented  with  freely  opening  the 
wound  by  one  or  more  long  incisions,  situate  as  much 
as  possible  on  the  anterior  aspect  of  the  limb.  The 
openings  thus  made  are  kept  gaping  by  means  of  com- 
presses placed  in  the  mouth  of  the  wound,  or  short 
lengths  of  very  large  rubber  drainage  tube.  Compresses 
or  tampons  are  never  placed  in  the  interior  of  the 
wound. 

When  the  wound  has  been  thus  prepared,  and 
haemostasis  is  complete,  the  tissues  look  quite  clean. 
However,  we  are  never  quite  sure  of  having  cleansed 
the  wound  absolutely.  There  is  no  known  method 
of  ascertaining  the  bacteriological  condition  of  a  fresh 
wound  while  it  is  still  bleeding.  The  "  smears " 
which  would  immediately  inform  us  as  to  the  state  of 
wounds  more  than  twenty-four  hours  old,  and  from  a 
non-bleeding  surface,  are  of  no  use  at  this  stage. 
Cultures  give  no  results  before  the  end  of  twenty-four 
hours.  And  even  a  negative  culture  would  not  signify 
that   the  wound  was  not   infected.     In  reality,  in  fresh 


TECHNIQUE   OF   STERILISATION        99 

wounds,  microbes  are  localised  at  certain  points,  and 
if  the  specimens  are  not  taken  from  these  points,  the 
tubes  remain  sterile.  Therefore  we  must  refuse,  abso- 
lutely, immediate  closure  of  a  wound,  however  satis- 
factorily clean  its  appearance  As  it  is  impossible  to 
ascertain  precisely  its  state  as  to  infection,  the  patient 
would  run  grave  risk  if  it  were  sutured.  Often  has 
disaster  followed  premature  closing  of  wounds. 

4.  Cleansing  of  Compound  Fractures  or  Wounds  of 
Joints. — {a)  Cleaning-iip  a  Compound  Fracture. — The  in- 
cisions for  exploration  and  cleaning-up  of  compound  frac- 
tures should  always  be  very  free.  A  long  incision  is  no 
drawback,  because  it  can  be  sutured  two  or  three  weeks 
later.  Whenever  possible  these  incisions  are  made  on 
the  anterior  aspect  of  the  limb  in  such  a  way  that  the 
liquid  may  remain  in  contact  with  the  bony  ^fragments. 
Counter-openings  at  the  dependent  points  are  not  made. 
Soft  parts  are  laid  open  in  such  a  manner  that  all  parts 
of  the  seat  of  fracture  may  be  explored.  In  fractures 
of  the  femur,  it  is  peculiarly  important  to  make  an 
incision  so  long  that  the  masses  of  muscle  can  be 
retracted  sufficiently  to  lay  bare  the  fissures  in  the  bone, 
however  long  they  may  be.  These  long  incisions  should 
be  kept  open.  Muscular  masses  have  a  marked 
tendency  to  reunite  in  such  a  way  that  the  seat  of 
fracture  becorries  shut  off.  The  opening  can  be  kept 
gaping  by  means  of  short  pieces  of  rubber  tubing,  three 
centimetres  in  diameter,  which  are  kept  separate  from 
each  other  by  a  second  set  of  tubes  at  right  angles. 
Those  haematomata  which  form  along  the  sciatic  nerve 
and  in  the  sheath  of  the  femoral  vessels,  about  the 
popliteal  space  and  along   the   posterior  tibial  vessels, 


lOO     TREATMENT   OF   INFECTED   WOUNDS 

must  be  reckoned  with.  Whenever  found  in  this  condi- 
tion, these  sheaths  must  be  opened,  because  they  are 
protected  from  the  antiseptic  Hquid  and  become  starting- 
points  of  infection.  Exploration  of  the  soft  parts  some- 
times brings  to  light  tiny  splinters  which  have  perforated 
the  muscles.  These  are  removed  at  the  same  time  as 
the  lacerated  portions  of  muscular  tissue. 

Splinters  are  often  found  lying  free  between  the 
fractured  extremities  and  in  the  medullary  canal.  These 
splinters  are  removed.  The  medullary  canal  is  explored, 
and  in  the  case  of  longitudinal  fractures,  the  marrow  is 
removed.  All  splinters  adherent  to  the  periosteum  are 
preserved.  Experience  has  shown,  in  fact,  that  fractures 
so  treated  become  sterile,  heal  without  sinuses,  and 
rapidly  consolidate.  And,  on  the  contrary,  the  exten- 
sive removals  of  splinters  which  too  often  have  been 
practised  in  the  "  ambulances  "  at  the  front,  have  yielded 
deplorable  functional  results.  Even  very  serious  injuries 
of  the  bones  should  not  be  followed  by  immediate 
amputation,  except  in  the  cases  of  extensive  smashing- 
up  of  the  skeleton,  or  of  destruction  of  vasculo-nervous 
bundles.  Careful  cleansing,  as  conservative  as  possible, 
should  be  made  of  the  multiple  seats  of  fracture,  with 
the  object  of  placing  the  conducting  tubes  in  contact 
with  bony  surfaces.  Thus  it  becomes  possible  to  save 
many  limbs  which  otherwise  would  be  condemned  to 
amputation. 

Most  careful  haemostasis  is  practised.  But  avoid 
leaving  compresses  in  the  deeper  parts  of  the  wound,  or 
only  leave  them  there  for  a  few  hours. 

{b)  Cleansing  of  Joint-injuries, — Wounds  of  joints 
are  treated  in  different  ways,  according  as  the  synovial 


TECHNIQUE    OF   STERILISATION       loi 

membranes  are  alone  concerned,  or  the  bony  extremities 
in  addition. 

When  synovial  cavities  are  alone  concerned,  the  pro- 
jectile is  extracted,  and  the  joint  emptied  of  the  blood 
it  contains.  The  contaminated  region  is  isolated  from 
the  rest  of  the  joint  cavity  by  compress  or  suture,  and 
the  instillation  tube  is  placed  in  the  situation  previously 
occupied  by  the  foreign  body. 

If  the  bony  lesions  consist  simply  of  a  chafing  of  the 
surface,  or  perforation  of  one  of  the  extremities  by  a  pro- 
jectile, or  an  unimportant  fracture  of  an  epiphysis,  the 
course  to  take  is  almost  identical  with  that  we  have  just 
described.  The  only  addition  is  to  scrape  the  bony 
surface  which  has  come  into  contact  with  the  projectile 
or  with  shreds  of  clothing.  This  region  is  cut  off  as 
completely  as  possible  from  the  rest  of  the  articular 
cavity,  and  submitted  to  instillation  of  the  antiseptic 
liquid. 

Should  the  bony  lesions  be  very  extensive,  it 
becomes  necessary  to  perform  a  resection.  But  primary 
joint  resections  are  to  be  made  with  circumspection. 
Because,  chemio- therapy  often  allows  repair  of  extensive 
lesions  of  articulations,  which,  under  any  other  treatment, 
would  have  had  to  undergo  resection  of  the  osseous 
extremities. 

B.  Inflammatory  Period. — This  stage  may  begin 
about  six  or  eight  hours  after  the  incidence  of  the 
wound.  But  usually  it  starts  towards  the  twenty-fourth 
or  thirty-sixth  hour,  sometimes  not  until  after  the  lapse 
of  several  days. 

Two  quite  different  classes  of  phenomena  are  observed : 
gangrenous  infections  and  phlegmonous  infections.     The 


102     TREATMENT   OF   INFECTED   WOUNDS 

first  are  of  early  onset  and  rapid  progress.  The  second 
are  slower  to  appear,  more  tardy  in  evolution.  Both 
types  of  infectious  manifestation  may  coexist  in  the 
same  wound.  Their  symptoms  have  been  described 
by  the  classic  authors.  But  their  pathological  physio- 
logy is  little  known.  Only  it  is  recognised  that  the 
general  reaction  following  surgical  traumatism  is  much 
more  violent  during  the  inflammatory  period  than  during 
the  pre-inflammatory  stage.  Manipulation  and  lacera- 
tion of  tissues  may  set  up  grave  complications  when 
microbes  already  swarm  in  the  walls  of  the  wound.  We 
have  seen  cases  operated  on  at  the  expiration  of 
several  days  for  a  localised  infection,  present  signs  of 
septicaemia  and  die  after  this  interference  with  the 
focus  of  infection.  At  the  beginning  of  the  campaign, 
tetanus  at  times  occurred  a  few  hours  after  such  opera- 
tions. And  when  the  nature  of  the  infection  was 
less  alarming,  still  the  general  condition  of  the  patient 
remained  worse  than  before,  and  his  temperature  chart 
showed  great  fluctuations  for  several  days  afterwards. 
Hence,  whilst  the  toilet  of  a  war-wound  should  be 
carried  out  in  minute  detail  before  the  advent  of  in- 
flammatory phenomena,  it  is  prudent  to  confine  one- 
self to  what  is  strictly  necessary,  during  the  stage  of 
confirmed  infection. 

The  course  to  adopt  varies  according  as  the  infection 
is  of  the  gangrenous  or  the  phlegmonous  type. 

I.  Gas-producing  Infection. — Gas-gangrene  presents 
itself  under  three  difl*erent  forms :  the  septicaemic  type, 
the  grave  local  type,  and  gas-cellulitis. 

(a)  The  septicaemic  form  is  particularly  frequent  in 
fractures  of  the  femur  with  serious  muscular  laceration. 


i 


TECHNIQUE    OF  STERILISATION       103 

After  a  few  hours  the  patient  has  nausea  and  vomits. 
He  is  agitated.  The  pulse  is  rapid,  small,  indistinct. 
However,  the  patient  does  not  yet  complain  of  great  pain 
in  his  limb,  and  there  is  little  gas  to  be  discovered.  This 
appears,  clinically,  several  hours  later  than  the  general 
phenomena.  Death  comes  before  the  limb  has  had 
time  to  necrose.  Amputation  is  urgent,  to  have  even  a 
feeble  chance  of  saving  the  patient's  life. 

{b)  Local  gas-producing  infection,  which  does  not  act 
at  the  very  outset  on  the  patient's  general  condition,  if 
suitable  treatment  be  adopted,  is  the  most  frequently 
recovered  from.  Two  principal  forms  may  be  distin- 
guished, a  superficial  and  a  deep  form.  The  superficial  gan- 
grene evolves  chiefly  in  the  sub-cutaneous  cellular  tissue. 
Gas  rapidly  spreads,  far  from  the  site  of  trauma.  Open- 
ing-up  shows  that  cellular  tissue  almost  alone  is  invaded, 
and  that  muscles  are  not  gangrenous,  save  in  the  imme- 
diate neighbourhood  of  the  wound.  This  form  is  fairly 
benign.  Numerous  incisions  implicating  at  the  same 
time  both  the  skin  and  the  superficial  fascia  are  made 
wherever  crepitation  can  be  felt.  Tubes  are  placed  in 
each  incision. 

Deep  gangrene  concerns  more  particularly  the  muscles. 
Pain  and  agitation  are  often  the  earliest  symptoms. 
Pain  extends  in  the  direction  of  the  trunk,  along  muscular 
sheaths.  It  is  the  path  which  the  infection  itself  has 
followed.  If  the  limb  is  not  yet  completely  necrosed,  it 
is  needful,  after  having  set  free  the  muscles  attacked,  to 
open  up  vascular  sheaths.  When  the  muscles  of  the 
calf  are  attacked,  the  femoral  sheath  should  be  incised 
between  Scarpa's  triangle  and  Hunter's  canal.  Finally, 
all    around    the    limb    are    made    incisions    about    ten 


I04     TREATMENT   OF    INFECTED   WOUNDS 

centimetres  (four  inches)  long,  including  both  skin  and 
fascia.  This  local  form  may  call  for  amputation.  If 
muscles  are  found  to  be  gangrenous,  and  in  addition  the 
vessels  obliterated,  it  is  prudent  to  remove  the  limb. 

Amputation  is  practised  at  a  short  distance  from  the 
seat  of  injury.  Moreover,  the  vascular  sheath  must  be 
laid  open,  in  order  to  make  sure  that  infection  has  not 
already  invaded  it.  The  stump  is  left  quite  open.  A 
tube,  perforated  with  small  holes  in  its  middle  third,  is 
placed  loop-wise  on  the  stump  (Fig.  34).  At  the  same 
time  instilling  tubes  are  placed  in  the  vicinity  of  the 
vascular  sheaths.  After  an  amputation  of  the  thigh, 
three  tubes  are  used — for  the  internal  saphenous,  the 
femoral  vessels,  and  the  profunda. 

{c)  Localised  Gangrene. — This  is  a  benign  form  of 
gas-producing  gangrene.  It  is  often  found  localised 
in  a  muscular  sheath.  For  example,  it  may  be  limited 
to  the  anterior  muscles  of  the  leg,  or  the  peroneal 
muscles.  It  may  even  affect  only  part  of  a  muscle. 
To  lay  it  open  freely  will  suffice,  the  incisions  extending 
beyond  the  lesion  in  every  direction.  Then  the  instilla- 
tion tubes  are  placed  in  position,  care  being  taken  to 
lead  them  into  muscular  interstices  and  into  the  muscles 
themselves.  The  course  of  local  gas-gangrene,  under  the 
influence  of  hypochlorite  of  soda,  is  very  favourable. 
Swelling  and  redness  disappear,  the  junction  of  the 
limb  with  the  trunk  remains  supple  and  free  from 
oedema,  the  patient  is  no  longer  in  pain,  and  his  general 
condition  is  excellent.  Elimination  of  mortified  tissues 
takes  place  very  quickly,  because  hypochlorites  dissolve 
necrosed  muscle.  Often  by  the  seventh  day,  there  is  no 
longer  a  trace  of  gangrenous  tissues. 


TECHNIQUE    OF   STERILISATION       105 

A  still  more  benign  form  of  gas-producing  infection 
exists,  gas-abscess.     A  simple  incision  will  suffice. 

2.  Phlegmonous  Form. — The  clinical  aspects  of  the 
phlegmonous  form  are  extremely  varied.  Reticular 
lymphangitis  may  be  seen  around  a  superficial  wound, 
or  a  line  of  inflammation  of  a  lymphatic  trunk  extending 
to  the  proximal  extremity  of  the  affected  limb,  or  a 
serious  local  inflammation  with  redness  and  great  swelling 
of  the  limb,  or  slight  inflammation  coincident  with  a 
grave  general  condition.  In  the  case  of  lymphangitis 
of  either  variety,  the  wound  is  sterilised  by  Dakin's 
solution,  and  a  hot  fomentation  applied  over  the  limb. 
If  a  lymphangitic  abscess  should  form,  it  is  incised  and 
the  cavity  sterilised  by  Dakin's  solution. 

When  the  muscles  are  concerned  in  the  injury,  and 
the  phlegmonous  inflammation  extends  to  the  whole 
thickness  of  a  muscle-group,  it  is  necessary  to  lay  open 
the  focus  of  inflammation,  and  also  the  intermuscular 
spaces  in  which  the  infection  is  being  produced  (generally 
due  to  haematoma).  But  surgical  interference  should 
be  limited  to  this.  It  is  not  wise  to  seek  for  projectiles 
or  foreign  bodies,  nor  to  remove  the  splinters  from  a  seat 
of  fracture.  In  these  highly  infected  wounds,  meticulous 
exploration  is  more  dangerous  than  useful.  The  seat  of 
fracture  is  kept  freely  open,  and  into  every  diverticulum 
is  inserted  an  instilling  tube.  It  is  dangerous  to  use  the 
scalpel  to  wounds  from  which  blood-stained  serum  is 
coming.  An  attempt  must  be  made,  in  the  first  place, 
to  lessen  the  infection  by  antiseptic  treatment.  If  a  tube 
instilling  hypochlorite  can  be  introduced  into  the  track 
resulting  from  a  previous  operation,  it  is  well  to  be  con- 
tent with  this  therapeusis.     Perhaps   it   may  be  needful 


io6     TREATMENT   OF    INFECTED   WOUNDS 

to  lay  open  a  wound  still  more  freely  in  order  to  introduce 
the  tube  which  will  supply  the  antiseptic  liquid.  Then 
an  incision  is  made  in  which  one  or  two  tubes  are  placed 
quite  in  the  bottom  of  the  track,  without  further  trauma- 
tism of  the  tissues.  At  the  same  time,  rigorous  immo- 
bilisation of  the  limb  is  insisted  on. 

To  resume,  the  treatment  of  a  patient  with  a  phleg- 
monous wound  differs  from  the  treatment  of  a  case  in 
the  pre-inflammatory  stage.  Preventive  therapeusis  of 
infection  calls  for  minute  surgical  cleansing,  which  at 
that  stage  of  infection  presents  no  danger.  But  when, 
on  the  contrary,  infection  is  well  established  in  a  wound, 
it  is  necessary  in  the  first  place  to  check  it  by  the 
simplest  means  at  hand,  and  to  postpone  to  a  more 
favourable  opportunity  the  surgical  treatment  called  for 
by  anatomical  lesions  and  the  presence  of  projectiles. 

Some  modifications  have  to  be  made  in  this  technique, 
due  to  the  nature  of  the  injury. 

{a)  Infected  Fractures.  —  The  course  to  pursue  in 
compound  fractures,  the  seat  of  acute  diffuse  inflamma- 
tion, is  similar  to  that  we  have  just  laid  down  for  wounds 
of  the  soft  parts.  Only  what  is  strictly  necessary  is  done 
in  the  first  place ;  that  is  to  say,  simple  laying  open  of 
a  seat  of  fracture  without  minute  cleansing,  and  the 
placing  of  several  instillation  tubes  in  the  diverticula  of 
the  wound.  After  a  few  days  the  general  condition 
improves.  Swelling,  redness,  pain,  diminish.  Then, 
when  the  dangerous  stage  of  infection  is  passed  and 
the  number  of  microbes  per  field  of  the  microscope 
remains  considerable,  the  toilet  of  the  seat  of  fracture 
is  made.  This  new  interference  is  as  complete  as  pos- 
sible.    Foreign    bodies,  carefully  registered  by  suitable 


TECHNIQUE    OF   STERILISATION       107 

apparatus,  are  removed  at  the  same  time  as  the  splinters, 
but  the  periosteum  of  the  sphnters  is  preserved  with 
care.  The  operation  ends  by  arranging  in  the  seat  of 
fracture  multiple  tubes  destined  for  supply  of  the  anti- 
septic solution. 

{b)  Snpptirating  Joint-injuries. — In  arthritis  without 
bony  lesions,  arthrotomy  more  or  less  free,  followed  by 
the  extirpation  of  foreign  bodies  and  cleansing  of  the 
articulation,  suffices  generally  to  ward  off  evil  results, 
if  the  antiseptic  treatment  be  carefully  employed  and 
the  joint  immobilised  absolutely. 

In  joint-injuries  with  bone  lesions  intervention  is 
limited  to  the  measures  which,  aided  by  chemical  steri- 
lisation, check  the  spread  of  infection.  The  general 
condition  of  the  patient,  the  nature  and  the  virulence  of 
the  infection,  play  an  important  part.  Streptococcal  infec- 
tions are  the  most  grave,  and  call  for  more  extensive 
interference  than  the  other  infections.  In  these  cases, 
sometimes,  the  prospect  of  amputation  must  be  faced. 

{c)  Secondary  Haemorrhage. — Haemorrhages  are  often 
due  to  the  detachment  of  a  scar  produced  by  contusion 
of  the  wall  of  a  large  arterial  trunk.  But  they  arise  also 
from  the  breaking  down  of  clot,  which  had  previously 
brought  about  spontaneous  haemostasis  of  a  wound  of 
artery  or  vein.  The  clot  disappears  under  the  influence 
of  infection,  and  the  artery  finds  itself  more  or  less 
widely  open.  In  this  manner  a  primary  haemorrhage 
is  produced,  perhaps  only  slight,  but  which  is  followed 
some  days  later  by  a  loss  of  blood  much  greater,  often 
mortal.  Haemorrhage  may  also  follow  the  loosening  of 
a  ligature,  silk  being  readily  dissolved  by  hypochlorite, 
as    Fiessinger   has    shown.      That   is   why   we   ligature 


io8     TREATMENT   OF    INFECTED   WOUNDS 

vessels   with   catgut   or   chromic   catgut.      When   these 
precautions  are  taken,  haemorrhages  are  never  observed. 

The  preventive  treatment  of  haemorrhage  consists  in 
careful  examination  of  the  vessels  at  the  time  of  surgical 
interference,  and  in  bringing  about  definite  haemostasis 
if  a  vessel  be  wounded. 

When  a  case  presents  a  primary  haemorrhage,  most 
frequently  a  tampon  will  stop  the  bleeding.  But  several 
days  later  a  new  haemorrhage  will  not  fail  to  appear,  and 
the  patient  may  succumb.  It  will  not  do  to  be  content 
with  a  tampon  ;  ligatures  must  be  used  above  and  below 
the  injury,  and  as  near  as  possible  to  the  seat  of 
ulceration. 

Haemorrhages  have  occurred  in  certain  hospitals  after 
using  badly  prepared  Dakin's  solution.  The  solution 
then  contains  free  alkali,  which  is  just  as  capable  of  pro- 
ducing vascular  ulceration  as  eau  de  Javel  or  Labar- 
raque's  liquor. 

In  wounds  chemically  sterilised  the  classic  secondary 
haemorrhages  due  to  suppuration  are  never  seen. 

C.  Suppuration  Stage. — The  manipulation  of  wounds 
which  have  arrived  at  the  stage  of  suppuration  is  made 
with  all  the  more  precaution  because  still  nearer  the 
inflammatory  stage.  Two  extreme  types  of  suppurating 
wounds  may  be  present.  The  first  type  is  the  wound 
covered  with  pus  more  or  less  blood-stained,  accom- 
panied by  lymphangitis,  swelling  and  pain.  It  is  the 
transition  period  between  the  inflammatory  stage  and 
the  period  of  true  suppuration.  Unless  there  are  urgent 
indications  to  the  contrary,  these  suppurating  wounds 
must  be  treated  with^  as  much  respect  as  wounds  in  the 
inflammatory  period.     The  other  type  is  represented  by 


TECHNIQUE    OF   STERILISATION       109 

wounds  of  longer  standing.  From  the  orifice,  already 
covered  by  granulations,  thick  "  laudable  "  pus  escapes. 
The  tissues  are  no  longer  oedematous.  The  tempera- 
ture is  only  slightly  raised,  or  presents  great  variations. 
At  this  stage  it  is  possible  to  interfere  surgically  with 
less  danger  than  in  wounds  of  the  first  type.  Between 
these  two  extreme  types  a  number  of  intermediate  con- 
ditions are  found.  Surgical  interference  becomes  less 
and  less  dangerous  as  the  wounds  are  removed  further 
and  further  from  the  first  type.  In  a  general  way  the 
cleansing  of  the  wound  follows  the  same  rules  in  all 
cases ;  the  more  inflamed  the  wound  the  more  sparing 
should  be  surgical  interference. 

1st.  Chemical  Cleansing. — In  the  great  majority  of 
cases  the  wounded  who  arrive  at  the  hospital  at  the  end 
of  two,  ten,  or  fifteen  days  have  already  been  operated 
upon.  On  the  surface  of  the  limb,  therefore,  openings 
are  found  leading  down  to  the  solutions  of  continuity 
in  soft  parts,  to  opened  joints,  to  seats  of  fracture.  These 
openings  are  often  too  small,  and  inadequate  to  drain  the 
pus-laden  burrows.  Nevertheless,  it  is  better  not  to  inter- 
fere at  the  outset.  Even  at  this  stage  it  is  hardly  wise  to 
open  up  an  abscess.  It  is  enough  to  remove  the  drainage 
tubes  which  generally  have  been  placed  in  the  wound, 
and  replace  them  by  the  small  instillation  tubes  which 
are  gently  coaxed  into  the  orifices  already  in  existence, 
down  to  all  the  diverticula  of  the  soft  parts  and  to  the 
seats  of  fracture.  This  is  done  without  anaesthesia  and 
without  distressing  the  patient.  Then  Dakin's  solution  is 
instilled,  according  to  the  method  which  will  be  described 
later,  until  suppuration  ceases,  temperature  drops,  and 
the  general  condition  improves.     From  the  clinical  point 


no    TREATMENT   OF   INFECTED   WOUNDS 

of  view,  suppuration  disappears  after  the  lapse  of  a  space 
of  time  varying  from  twenty-four  hours  to  about  four  days. 

2nd.  Siu?gical  Cleaning. — After  a  Httle  time,  in 
wounds  accompanied  by  injuries  to  bone,  the  ameliora- 
tion resulting  from  the  application  of  the  antiseptic  is 
arrested.  The  number  of  microbes  found  on  the  surface 
of  the  wound  remains  stationary.  But,  on  the  other 
hand,  suppuration  has  diminished  or  dried  up,  the  tissues 
are  no  longer  swollen,  and  the  patient  is  ready  for 
surgical  interference. 

Then  the  wound  is  cleansed  just  as  though  it  were 
a  fresh  one.  Under  anaesthesia,  foreign  bodies  and 
necrotic  tissues  are  removed.  In  fractures  the  free 
splinters  are  resected,  and  by  means  of  a  sharp  periosteal 
elevator,  the  periosteum  is  detached  from  irregular  bon)' 
surfaces  containing  microbes.  As  sparingly  as  possible 
the  bony  extremities  have  their  irregularities  removed. 
All  tissues  likely  to  necrose  are  carefully  taken  away. 

In  a  case  of  suppurative  arthritis,  if  necessary,  re- 
section of  the  bony  extremities  is  practised.  At  this 
stage  the  surgical  interventions  found  absolutely  neces- 
sary may  be  carried  out  with  much  less  danger  than 
when  the  patient  "  came  in."  It  must  be  borne  in  mind, 
however,  that  tissues  which  have  already  commenced  to 
cicatrise  during  the  stage  of  suppuration  are  impregnated 
with  microbes  and  that  reinfections  are  possible.  There- 
fore operations  involving  the  least  possible  amount  of 
traumatism  should  be  chosen. 

Wounds  of  the  soft  parts,  as  a  rule,  become  aseptic 
under  the  influence  of  the  antiseptic  without  a  new 
operation  being  necessary. 

3rd.  Chemical  Sterilisation. — The  surgical  cleaning-up 


TECHNIQUE   OF   STERILISATION       in 

is  followed  by  the  introduction  of  instillation  tubes  pre- 
cisely as  though  dealing  with  a  fresh  wound.  It  is 
necessary  to  keep  the  wound  gaping  so  long  as  its 
deeper  parts  are  not  sterilised.  This  result  is  attained 
by  placing  in  the  wound  short  segments  of  tube  of  wide 
calibre,  by  the  side  of  which  are  introduced  the  small 
tubes  for  instillation. 

D.  Cicatricial  Stage. — The  cicatrisation  of  a  wound 
does  not  mark  the  end  of  infection.  In  fact,  microbes 
remain  included  in  the  cicatricial  tissue.  Therefore 
secondary  interference  practised  on  a  patient  whose 
wounds  have  healed,  during  a  period  of  suppuration 
more  or  less  long,  is  subject  to  special  rules.  Every- 
one knows  that  after  stump-trimming,  nerve-suture, 
osteotomy  for  defective  union,  suture  for  pseudarthrosis, 
etc.,  infections,  sometimes  most  alarming,  may  arise.  It 
is  therefore  prudent,  in  these  secondary  interventions,  to 
refrain  from  suturing  the  wounds,  and  to  place  in  the 
deepest  parts  one  or  two  tubes  carrying  the  antiseptic 
liquid.  The  sterilisation  of  operation  wounds  is  thus 
rapidly  obtained,  and  the  accidents  due  to  reinfection 
avoided.  In  bone-grafting,  the  extremities  of  the  bone 
are  prepared  for  the  reception  of  the  graft,  and  in  the 
wound  thus  created  instillation  tubes  are  placed.  After 
a  few  days,  it  is  ascertained  that  the  wound  is  actually 
aseptic,  and  then  the  grafting  is  completed  and  the  soft 
parts  closed. 

In  a  word,  during  the  cicatricial  stage,  surgical  inter- 
ference practised  in  two  stages,  which  are  separated  by 
a  period  of  disinfection,  is  the  surest  means  of  avoiding 
disaster. 


CHAPTER    IV 

THE     TECHNIQUE     OF     THE     STERILISATION 
OF     WOUNDS  —  CHEMICAL     STERILISATION 

ChEiMICAL  sterilisation  of  a  wound  is  brought  about  by 
instillation,  continuous  or  intermittent,  of  an  antiseptic 
liquid,  by  means  of  small  rubber  tubes,  into  all  the 
recesses  of  a  wound.  As  the  quantity  of  liquid  used  is 
very  small,  it  is  not  necessary  to  employ  drainage  tubes 
or  to  arrange  for  reception  of  an  overflow.  The  liquid 
which  has  moistened  the  tissues  is  absorbed  by  the 
dressing  and  evaporates.  Instillation  thus  practised 
permits  of  the  continual  renewal  of  the  liquid  over  every 
portion  of  the  wound.  This  procedure  differs  from  the 
old  "  irrigation,"  in  that  it  is  much  simpler,  and  in  that 
the  liquid  is  carried  directly  to  the  deepest  diverticula 
of  the  wound. 

I.  Conducting  Tubes  and  Reservoirs 

A.  The  Conducting  or  "Instillation"  Tubes.— The 
conducting  tubes  are  of  red  rubber.  The  rubber  wall 
of  the  tube  has  a  thickness  of  i  mm.,  and  the  interior 
diameter  is  4  mm.  They  are  thus  resistant  and  flexible. 
These  qualities  allow  of  their  penetration  to  every  irregu- 
larity of  the  wound,  and  of  their  adequate  resistance  to 

112 


TECHNIQUE   OF   THE    STERILISATION     113 

the    pressure  of  muscles    and    dressings.     Three   kinds 
of  tubes  are  used. 

1st.  Tubes  perforated  with  Small  Holes. — The  length 
of  these  tubes  varies  from  30  to  40  cm.  (roughly  12  to 
16  inches).  Some  of  them  are  closed  at  one  end  by  a 
ligature,  and  pierced  by  small  holes  over  a  length  of  from 
5  to  20  cm.^  from  the  closed  extremity  (Fig.  18).     The 


B  gBSBSSSB^^BS^SI^^Sm^^S^ 


■mmmsmmmam 


I'lG.   18.— Conducting  or  "instillation"  tubes,    rubber,    with   multiple   holes, 
closed  at  one  end. 

A.  Tube  30  cm.  long,  pierced  over  a  length  of  5  cm. 

B.  Tube  30  cm.  long,  pierced  over  a  length  of  10  cm. 

C.  Tube  40  cm.  long,  pierced  for  a  length  of  15  cm. 

D.  Tube  40  cm.  long,  pierced  for  a  length  of  20  cm. 

E.  Tube  open  at  both  ends,  and  pierced  over  a  length  of  20  cm.  in  its 

median  portion  (10  cm.  —  about  4  inches). 


holes  number  about  eight  to  each  5 -cm.  section.  Their 
diameter  is  about  half  a  mm.^  The  holes  are  made  by 
means  of  an  ordinary  punch.  These  tubes  are  the  most 
used.  Four  different  categories  are  in  use,  according  as 
the  holes  are  perforated  over  a  length  of  5,  10,  15,  or 
20  cm.      Other  tubes   are   left  open   at   each    end   and 

'  Say  2  to  8  indies. 
^  j\yth  of  an  inch. 


114     TREATMENT   OF    INFECTED   WOUNDS 

pierced  with  holes  only  in  their  middle  third  (Fig.  1 8,  E). 
Liquid  enters  by  each  end. 

2nd.  Tubes  with  a  Single  Opening. — These  are  of  a 
length  of  from  25  to  30  cm.^  and  the  ends  are  open 
(Fig.  19).     At  half  a  centimetre  from  one  end  a  large 

Fig.  19. — Conducting  or  "  instillation"  tube  with  terminal  opening.     Tube  of 
about  30  cm.  long,  open  at  both  ends,  with  a  lateral  opening  near  one  end. 

lateral  opening  is  made.  This  lateral  orifice  is  intended 
to  permit  the  egress  of  liquid  should  the  terminal  orifice 
become  blocked. 

3rd.  Tubes  perforated  with  Small  Holes  and  covered 
with  Absorbent  Fabric. — These  tubes  are  closed  at  one 
extremity  and  pierced  with  small  holes  over  a  variable 
length.  The  section  pierced  with  little  holes  is  covered 
with  a  sheath  of  fabric  similar  to  the  material  of  which 
bath  towels  are  made  (Fig.  20).     This  sheath  is  firmh* 


i 


•irm-  -  laT'r^.-'-nrr' 


Fig,  20. — Conducting  or  "instillation"  tube  covered  with  a  sheath  of  bath- 
towelling  (tissa  Sponge), 

stitched  to  the  tube.  It  is  intended  to  distribute  the 
liquid  over  the  whole  surface  of  the  tube  as  it  escapes 
from  the  holes.  It  is  important  that  the  cover  should 
be  so  firmly  fixed  by  a  stitch  to  the  rubber  tube  that  it 
cannot  remain  behind  in  the  recesses  of  the  wound 
when  the  tube  is  withdrawn. 

These  tubes  are  of  uniform  length.     They  can  easily 
be    lengthened   to  any  extent    by   means  of  pieces   of 

*  Say  9  to  12  inches. 


TECHNIQUE   OF  THE   STERILISATION     115 


rubber  tube  of  the  same  calibre  and  "  unions  "  of  pieces 
of  glass  tube  (Fig.  22,  C)  of  a  calibre  of  4  mm.  and  a 
length  of  2*5  cm. 

B.  The  Distributing  Tubes. — The  tubes  pierced  with 
holes  are  grouped  into  sets  of  two,  three,  or  four  by 


S5^^ 


I 


Fig.  21. — Glass  distributing  tubes  (vcrre 
de  Gentile). 

A.  Tube  with  one  branch. 

B.  Tube  with  two  branches. 

C.  Tube  with  three  branches. 

D.  Tube  with  four  branches. 


Fig.  22.— Glass  connecting  tubes,  '  'unions." 

A.  Cyhndrical  tube  of  a  length  of  4  to 
5  cm.  and  an  interior  diameter  of 
7  mm. 

B.  Y-tube  with  an  interior  diameter  of 
7  mm.  These  tubes  unite  the  ends 
of  rubber  irrigating  tubes. 

C.  Cylindriccil    tube  of    a    length   of 

3  cm.  and   an   interior  diameter  of 

4  mm.  This  tube  serves  to  join-up 
two  small  conducting  tubes,  when 
it  is  necessary  to  add  to  the  length 
of  one  of  these  tubes. 


means   of  appropriate  branched  tubes.     Two   types  of 
branched  tubes  are  employed  (Fig.  21). 

1st.  The  Y-shaped  tube  is  composed  of  a  main  stem 
about  2  cm.  long  with  a  calibre  of  7  mm.,  and  of  two 
limbs  or  branches  of  equal  length,  about  2  cm.,  whose 
interior  calibre  varies  between  3  and  4  mm.  (Fig.  21,  B) 


ii6    TREATMENT   OF    INFECTED    WOUNDS 

Upon  the  two  branches  are  fitted  either  two  simple 
instillation  tubes,  or  the  two  extremities  of  a  tube  per- 
forated with  holes  in  its  middle  portion. 

2nd.  The  distributor  with  four  branches  is  composed 
of  a  glass  tube  closed  at  one  end,  6  or  7  cm.  long,  and  of 
a  calibre  of  7  mm.  (Fig.  21,  D).     From  one  side  of  this 
tube  project  at  right  angles  four  smaller  tubes,  each  of  a 
length  of  2  cm.  and  an  interior  calibre  of  3   to  4  mm. 
Thus  it  has  the  look  of  a  comb.     In  the  same  manner 
one  may  have  three  branches  (Fig.  21,  C),  or  five  or  six. 
3rd.  Small  glass  connecting  tubes  or  "  unions  "  must 
also  be  at  hand  to  join  together  the  rubber  tubes  of  large 
or  small  calibre,  or  to  unite  a  rubber  tube  of  small  calibre 
to  one  of  large.     The   first    are  cylindrical  glass  tubes 
2  to  3  cm.  long,  aiid  of  a  calibre  of  4  and  of  7  nnii. 
(Fig.  22,  A  and  C).     The  others  are  conical  glass  tubes 
of  the  same  length,  presenting  at  one  extremity  an  in- 
terior diameter  of  3  to  4  mm,,  and  at  the  other  extremity 
an  interior  diameter  of  7  mm.  (Fig.  21,  A).     Tubes  of 
Y-shape  are  also  in   use,  of  7   mm.  calibre,  for  joining 
up  irrigating  tubes  (Fig.  22,  B). 

C.  The  Irrigating  Apparatus.— The  irrigating  appa- 
ratus is  composed  essentially  of  a  reservoir  (ampoule  or 
flask)  fixed  at  a  certain  height  above  the  patient's  bed, 
with  a  tube  (equipped  or  not  with  a  drop-counting  con- 
trivance) and  stop-cock,  so  as  to  allow  of  either  continuous 
or  intermittent  instillation. 

I  St.  The  reservoir  for  liquid  usually  employed  is  a 
flask  holding  a  litre  (176  pint,  0*22  gallon).  Its  interior 
orifice  has  a  diameter  of  7  mm.  (Fig.  23).  To  this 
is  attached  an  irrigating  tube  of  red  rubber  with  a 
calibre  of  7    mm      The  flask  is   fastened   to   a   wooden 


TECHNIOUK    OF  TlIK    STERILISATION     ti; 

standard  firmly  fixed  to  some  convenient  portion  of 
the  bedstead,  a  portion  which  depends  upon  the 
situation  of  the  wound.  It  is  suspended  at  a  height 
of  from  50  cm.  to  i  metre  above  the  level  of  the 
bed. 

2nd.  The  irrigating  tube,  as  we  have  just  said,  has 
an  interior  diameter  of  7  mm.     Its  length  is  from  i  metre 


Fir;.  23. — Ampoule  or  flask  holdino;  a       Fio.  24. — Pinchcock  [Pince  df  Mohr 
litre.  d  ressorf), 

50  cm.  to  2  metres.  Whilst  the  superior  extremity  is 
attached  to  the  flask,  its  lower  end  is  united  with  a  glass 
cannula,  to  which  are  fixed  the  smaller  tubes  which 
convey  the  liquid  to  the  wound.  At  lo  centimetres 
below  the  flask  the  tube  is  furnished  with  a  pinch-cock 
(Fig.  24).  Slight  pressure  upon  the  spring  suffices  to 
open  the  lumen  of  the  tube  and  to  allow  the  liquid  to 
flow.      This  apparatus   is   extrerriely   simple,    and   well 


ii8     TREATMENT   OF   INFECTED   WOUNDS 

suited  to  the  intermittent  irrigation  of  wounds  (Fig. 
25).  Every  two  hours  a  nurse  stops  at  the  foot 
of  the  bed  and  releases  the  spring  of  the  "  pince 
de  Mohr  "  for  a  few  seconds.  Instillation  at  once  takes 
place. 

In  the  hospitals  at  the  front,  where  it  is  difficult  to 


f .....       iU 

Fig.  25. — Nurse  using^a  pinchcock  and  so  instilling  antiseptic  liquid. 

provide  the  needful  number  of  apparatus,  the  plan  devised 
by  le  medecin-major  Ferret  may  be  used.  This  consists 
of  a  support  on  wheels  (dressing  wagon)  carrying  the 
reservoir  of  Dakin's  solution  at  the  required  height. 
The  orderly  propels  the  wagon  from  bed  to  bed  and 
injects  the  liquid  into  the  wounds  by  means  of  a  cannula, 


TECHNIQUE   OF   THE    STERILISATION     119 

which  is  changed  for  each  patient.  This  proceeding 
simplifies  the  provision  of  apparatus,  but  greatly  adds 
to  the  work  of  the  staff. 

The  liquid  may  be  instilled  also  by  means  of  a 
syringe.  The  most  convenient  syringe  for  this  purpose 
has  been  made  by  Gentile.  It  consists  simply  of  a 
glass  tube  drawn  out  to  a  fine  jet  at  one  end,  and  of 
a  capacity  of  10  c.c.  (Fig.  26).  The  piston  is  replaced 
by  a  bulb  of  red  rubber.  The  advantage  of  this  syringe 
is  that  it  can  be  used  with  one  hand.  Each  case  has 
its  own  syringe.  It  is  kept  half-immersed  in  the 
bottle  which  holds  the   supply  of  Dakin's  solution   be- 


FiG.  26.— Syringe  [Seringiie  dc  Gentile), 

longing  to  the  case.  The  use  of  a  syringe  for  the 
instillation  of  liquid  has  also  the  drawback  of  increasing 
the  work  of  the  personnel.  Besides,  instillation  done 
with  a  syringe  gives  results  far  less  speedy  than  with  the 
irrigating  ;  reservoir,  because  the  quantity  of  liquid  is 
much  less  considerable  ;  and,  the  tube  constituting  a 
siphon,  the  moment  the  syringe  is  withdrawn  the  liquid 
immediately  runs  out  of  the  wound  instead  of  remaining 
there. 

We  have  completely  given  up  the  use  of  the  syringe 
for  instillations.  We  use  Gentile's  syringe  to  test  the 
permeability  of  the  tubes  in  the  course  of  doing  the 
dressings. 


120     TREATMENT   OF    INFECTED   WOUNDS 

When  it  is  desired  to  practise  continuous  instillation 
instead  of  intermittent,  the  apparatus  is  modified  after 
the  following  manner.  To  the  lower  aperture  of  the 
flask  is  attached  a  rubber  tube  lo  cm.  long.  At  the 
extremity  of  this  tube  is  attached  one  of  Gentile's  "  drop- 
counters"  {line  ampoule  compte-goiittes  de  Geyitile).  Be- 
tween the  drop-counter  and  the  reservoir  is  a  screw 
pinchcock  {nne  pince  de  Mohr  a  vis)  which  enables  us  to 


Fig.  27. — ' '  Drop-counter,"  Gentile's.    Screw  pinch-cock  {Pince  de  Mohr  a  vis). 


regulate  the  number  of  drops  per  minute  which  the 
apparatus  should  deliver.  The  lower  end  of  the  drop- 
counter  is  connected  to  the  irrigating  tube  (Fig.  27). 
As  the  quantity  of  liquid  which  traverses  a  section  of 
tube  in  a  unit  of  time  is  veiy  small,  it  is  useless  to 
employ  an  irrigating  tube  of  diameter  as  great  as  that  in 
use  for  intermittent  instillation.  A  calibre  of  5  to  6  mm. 
is  sufficient. 


TPXHNIOUK    OF   THE    STERILISATION     121 

D.  Method  of  using^  the  Different  Tubes  and  Apparatus. 
—  1st.  The  appliance  for  continuous  instillation  should 
never  be  connected  up  with  several  tubes,  nor  with  a 
tube  perforated  with  several  holes.  As  the  output  of  a 
drop-counter  is  very  small,  all  the  liquid  should  flow 
through  a  single  tube  and  emerge  from  a  single  hole  in 
this  tube,  the  hole  and  the  tube  being  dependent  on 
gravitation.  Consequently,  instillation  drop  by  drop 
should  only  be  used  for  wounds  which  contain  a  single 
tube,  perforated  at  its  extremity  (Fig.  28),  or  a  single 
tube  sheathed  with  "  tissu  cponge  "  (bath-towelling). 

2nd.  The  apparatus  for  intermittent  instillation  can 
be  connected  up  with  four  tubes  perforated  with  tiny 
holes,  or  even,  in  certain  cases,  with  eight.  As  the 
yield  of  the  irrigating  tube  is  considerable,  the  liquid, 
at  the  moment  when  the  spring  of  the  pinchcock  is 
released,  spurts  out  from  all  the  holes  of  all  the  tubes. 
As  much  as  possible,  tubes  of  a  length  of  5  and  of  10  cm. 
should  be  used,  especially  if  a  single  flask  furnishes  the 
liquid  to  eight  tubes. 

It  will  not  do  to  serve  from  the  same  cannula  both 
simply-perforated  tubes  and  tubes  sheathed  in  "tissu 
eponge."  By  reason  of  the  different  resistances,  the 
liquid  would  escape  almost  entirely  by  the  simply 
perforated  tubes. 

It  is  important  to  remember  this  difference  in  the 
action  of  the  two  forms  of  apparatus,  for  continued 
instillation  and  for  intermittent  instillation,  because,  if 
a  drop-counting  appliance  be  used  in  connection  with 
a  system  of  general  perforated  tubes,  no  result  will  be 
obtained.  The  device  for  intermittent  instillation  is 
used    much    more    frequently    than    the    apparatus    for 


122     TREATMENT   OF   INFECTED   WOUNDS 


continued  instillation,  because  it  allows  a  single  irrigation 
reservoir  to  provide  liquid 
for  four  or  eight  tubes  at 
once  (Fig.  29).  It  is  there- 
fore applicable  to  all  large 
wounds. 


Fig.  28. — Apparatus  arranp^ed  for  drop 
by  drop  instillation:  a.  Reservoir;  /', 
Irrigation  tube  ;  c.  Screw  pinchcock  ; 
d.  Drop-counter  ;  (\  Distributing  tube 
{Fig.  2T,  A)  ;  /.  (Conducting  tube  with 
terminal  orifice  (Fig.  rg). 


Fin.  29. — Apparatus  for  intermittent 
instillation :  a.  Reservoir  {ampoule 
o)-  flask  holding  a  litre) ;  b,  Irrigating 
tube  with  a  diameter  of  7  mm.  ;  c, 
Pinchcock  {Pince  de  Mohr)  ;  </,  Dis- 
tributing tube  with  4  branches  ;  e. 
Conducting  tubes. 


TECHNIQUE   OF   THE   STERILISATION     123 


II.  Arrangement  of  the  Tubes  in  a  Wound 

A.  General  Principles. — The  disposition  of  the  tubes 
in  a  wound  is  such  that  the  liquid  may  readily  spread 
over  the  whole  surface.  As  it  is  essential  that  the  anti- 
septic liquid  should  be  in  contact  with  the  tissues  them- 
selves, the  tubes  are  not  applied  over  gauze,  or  over 
"  wicks,"  but  directly  to  the  wound.  In  fact,  a  thin 
compress  placed  on  the  surface  of  granulations  might  be 
supposed  to  be  able  to  distribute  the  liquid  over  the 
whole    extent    of    their    surface.       Also    it    might    be 


^^S"*'^ 


Fig,   30. — Wound  with  surface  horizontal.     Vv'rong  method  of  placing  tlie 
tube.    The  perforated  instillation  tube  is  on  the  surface  of  the  compress. 


imagined  that  "wicks"  of  absorbent  cotton  would  play 
a  similar  part.  But  nothing  of  the  kind  occurs.  After 
a  short  time,  the  deeper  parts  of  the  absorbent  tissue 
become  impregnated  with  the  plasma  secreted  by  the 
tissues  and  are  then  almost  impermeable  to  the  liquid. 
Suppose  a  thin  compress  be  placed  on  the  surface  of  the 
wound  and  a  tube  be  laid  on  the  compress,  liquid 
injected  into  the  tube  slips  away  over  the  surface  of  the 
wound  without  sterilising  the  wound  (Fig.  30).  There- 
fore it  is  absolutely  necessary  to  place  the  tubes  directly 
in  contact  with  the  wound-surface,  and  then  to  lay  the 
compresses  above  them  (Fig.  31)  in  such  a  manner  that 


124     TREATMENT    OF    INFECTED    WOUNDS 

the  liquid  may   insinuate  itself  between   them   and  the 
surface  of  the  wound. 

In  the  disposal  of  the  tubes  it  is  necessary  also  to 
take  into  account  the  position  of  the  wound.     The  flow 


Fig,  31. — Wound  with  surface  horizontal.     Right  method  of  placing  the  tiabe.' 
Tube  in  contact  with  the  wound  and  covered  with  a  gauze  conii"»res.s. 

of  liquid  being  under  the  influence  of  gravity,  the  tubes 
are  arranged  differently,  according  as  the  wound  is 
situate  on  the  anterior,  lateral,  or  posterior  surface  of 
the  body.  They  are  placed  in  such  a  manner  that  the 
liquid  may  spread  itself  over  the  greatest  possible  extent 
of  the  wound  (Fig.  32).  When  the  wound  is  on  the 
anterior  surface  of  the  trunk  or  limbs  the  application 
of  the  tubes  is  easy.  If  on  the  lateral  or  posterior  aspect, 
prolonged  contact  between  antiseptic  and  wound  surface 
is  more  difficult  to  obtain. 

The  shape  of  the  wound  also  plays  an  important  part. 
A  wound  possessing  but  a  single  opening,  and  that 
situated  superiorly,  can  be  filled  with  liquid  like  a  cup, 
and  can  be  readily  sterilised  (Fig.  33).  If  a  wound  of 
this  type  has  a  second  opening  at  the  level  of  its  most 
dependent  part,  liquid  runs  through  rapidly  and  the 
sterilisation  is  slower.  Gravity  plays  a  very  consider- 
able part  in  the  distribution  of  the  liquid  and  the  tubes 
must  be  arranged  in  such  a  manner  as  to  utilise  it. 

B.  Arrangement  of  the  Tubes  according  to  the  Shape  of 
the  Wound,      ist.  Surface  Wounds. — One  or  more  tubes 


TECHNIQUE    OF   THE   STERILISATION     125 

perforated  with  minute  holes  are  placed  on  the  wound 
If  it  is  situated  on  the  anterior  aspect  of  the  body  and 
the  bottom  of  the  wound  is  in  the  horizontal  plane,  or 
nearly  so,  the  liquid   can  be   distributed  fairly  equally 


Kmrnw/Z/ffmrn 


Fig.  32. — ^Wound  with  surface  inclined. 

A.  Tubes  placed  the  wrong  way,  along 
the  lower  border  of  the  wound. 

B.  Tubes  placed  the  right  way,  along 
the  upper  border  of  the  wound. 


Fig.  2)'^)'  —  Wound  with  opening 
superior,  so  that  it  can  be  filled 
like  a  cup. 


over  its  surface  (Fig.  31).  When  the  surface  of  the 
wound  is  inclined,  the  tube  is  laid  along  the  more 
elevated  border  (Fig.  32),  so  that  the  liquid,  carried 
by  gravity,  flows  over  the  surface  of  the  tissues.  Instead 
of  a  simple  tube,  we  may  use  a  ring,  formed  out  of 
a  tube  perforated  with  little  holes  throughout  its  middle 


126     TREATMENT   OF   INFECTED    WOUNDS 

portion,  and  whose  ends  are  joined  by  a  Y-shaped 
cannula  (Fig.  34).  By  means  of  a  thread  attached  to 
the  two  halves  of  the  tube,  the  loop  can  be  altered  to 
any  convenient   shape.     On    the   end   of  a   stump,    for 


.^rr"^:f"^>. 


Fig.  34. — Surface  wound.  The  in- 
stillation is  made  by  means  of  a 
tube  perforated  in  its  middle  portion, 
whose  ends,  fixed  to  the  skin  by  a 
strip  of  adhesive  plaster,  are  joined 
by  a  Y-shaped  distributor. 


Fig.  35. — "  Seton  "  wound,  in  the 
interior  of  which  is  placed  an 
instillation  tube  perforated  with 
small  holes  and  which  passes 
through  the  dressing  at  its  upper 
part. 


example,  this  mode  of  instillation  is  useful.  Between 
the  raw  surface  and  the  base  of  the  flap  is  placed  a  loop 
formed  of  a  rubber  tube  pierced  with  multiple  holes 
whose  two  extremities  are  joined  by  the  Y-cannula 
resting  on  the  skin  of  the  anterior  portion  of  the  limb. 


TECHNIQUE   OF  THE   STERILISATION     127 

The  fixation  of  these  tubes  is  effected  by  means  of 
gauze  compresses  soaked  in  Dakin's  solution,  which  are 
laid  over  them.  In  addition,  they  are  fixed  to  the  skin 
adjoining  the  wound  by  a  strip  of  adhesive  plaster. 
This  fixation  must  be  thought  out  very  carefully,  because 
if  the  tubes  slip  down  to  the  lowest  part  of  the  wound, 
sterilisation  of  the  upper  part  will  be  defective.  For, 
whatever  precautions  may  be  taken,  the  tubes  some- 
times become  displaced.  That  is  why  it  is  advantageous, 
in  the  treatment  of  surface  wounds,  to  replace  instilla- 
tion of  liquid  by  the  application  of  chloramine  paste,  so 
soon  as  sphacelated  tissues  have  been  dissolved. 

2nd.  The  "  Seton"  Type  of  Wounds. — If  a  tube  closed 
at  one  end  and  pierced  with  small  holes  is  placed  in  a 
"  seton  "  wound  whose  axis  is  almost  horizontal,  liquid 
readily  remains  in  the  wound  (Fig.  35).  But  if  the  axis 
of  the  seton  is  vertical,  the  liquid  escapes  by  the  inferior 
opening  immediately  it  is  injected.  Therefore,  some- 
times, in  these  cases  a  tube  wrapped  in  "  tissu  eponge  " 
is  used.  This  absorbent  fabric  (Fig.  20)  distributes  the 
fluid  over  the  surface  of  the  wound  and  keeps  it  there 
for  a  period  more  or  less  prolonged. 

3rd.  Wounds  with  a  Single  Orifice. — If  the  opening  is  at 
the  "  roof"  of  the  wound,  the  device  is  simple.  A  rubber 
tube  bearing  a  single  hole  near  its  blind  extremity  is 
introduced  to  the  bottom  of  the  wound  (Fig.  36).  The 
cavity  of  the  wound  fills  up  like  a  cup,  and  the  fluid 
remains  quiescent  there  until  it  is  displaced  by  the  fresh 
liquid  brought  by  the  tube  to  the  bottom  of  the  wound. 
The  superior  opening  of  the  wound  should  be  large 
enough  to  allow  the  liquid  to  circulate  freely.  In  these 
cases,  "  drop  by  drop "  instillation  may  be  used.     The 


128     TREATMENT    OF    INFECTED   WOUNDS 

liquid  continually  arriving  at  the  bottom  of  the  wound 
is  constantly  being  renewed.  This  arrangement  is  par- 
ticularly favourable  to  rapid  sterilisation.  Therefore, 
wherever  possible,  it  is  well  to  transform  the  wounds 
with  two  openings  into  wounds  with  one  opening,  by 
closing  the  lower  aperture  with  a  tampon. 

When  the  opening  of  the  wound,  instead  of  being 
found  on  the  anterior  aspect  of  the  body,  appears  on  the 
posterior  surface,  conditions  are  altered.  If  the  patient 
can  sleep  prone  on  his  belly,  the  tube  is  placed  as  just 


Fig.  36. — Compound  Iractuie  of  tibia  willi  the  opening  of  the  wound  on  the 
anterior  aspect  of  the  hnib ;  in  the  beat  of  fracture  is>  a  tube  open  at  the 
end. 


described.  Otherwise  a  different  device  must  be  adopted. 
In  fact,  if  the  fluid  is  led  to  the  roof  of  the  wound  by  a 
tube  which  enters  by  the  lower  opening,  it  tends  to  fall 
back  immediately,  under  the  influence  of  gravity. 

When  the  wound  is  a  narrow  one,  a  tube  sheathed 
with  ".tissu  eponge  "  can  be  used,  which  may  carry  the 
liquid  by  capillary  attraction  to  the  highest  regions 
(Fig.  37).  If  the  wound  is  larger,  several  tubes  pierced 
with  little  holes  are  introduced  and  the  liquid  injected 
under  an  adequate  pressure.     The  liquid  spurts  out  over 


TECHNIQUE   OF   THE   STERILISATION     129 

the  walls  and    succeeds    in    sterilising   them,   but    more 
slowly  than  when  it  can  remain  quietly  in  the  wound. 

Should  the  orifice  occur  on  the  lateral  aspect  of  the 
body,  a  certain  amount  of  retention  of  the  liquid  can  be 
attained  b}^  compresses  plugging  the  orifice.  In  this 
case  tubes  pierced  with  small  holes  and  closed  at  one 
end  are  used.     In  addition,  the  patient  should  be  placed 


.^- 


/ 


Fig.  ^-j. — Wound  of  the  soft  parts  whose  orifice  is  at  the  posterior  aspect  of 
the  hnib.  Instillation  to  the  "roof"  of  the  wound  by  means  of  a  tube 
sheathed  in  "  bath-towelling  "  [tissu  eponge). 


in  the  position  most  favourable  for  retaining  liquid  in  the 
wound. 

4th.  Large  Wounds  with  Several  Openings. — Some- 
times, if  the  openings  are  on  the  anterior  surface  of  the 
limb,  these  wounds  can  be  filled  with  liquid.  Sterilisa- 
tion is  then  very  simple.  But  in  the  majority  of  cases 
it  is  not  so.     The  fluid  has  a  tendency  to  escape  rapidly 

9 


i3o    TREATMENT   OE   INEECTED   WOUNDS 

by  the  most  dependent  point  of  the  wound.  In  addition 
to  lesions  of  the  soft  parts,  there  is  often  a  fracture  which 
makes  the  wound  still  more  irregular. 

Then  tubes  perforated  over  a  length  of  5  to  10  cms. 
are  used,  and  introduced  as  deeply  as  possible  into  each 
diverticulum.     To  fix   these   tubes  in  their  positions  in 


Fig.  38. — Irregular  wound  of  the  thigh.  Two  tubes  are  placed  in  the  wound 
anteriorly  and  one  posteriorly.  These  tubes  are  applied  to  the  surface  of 
the  tissues.  They  are  kept  apart  by  gauze  packed  between  them  in  the 
opening  of  the  wound. 

the  central  part  of  the  wound,  gauze  compresses  may  be 
used.  But  it  is  important  to  see  that  the  compresses  are 
not  packed  too  tightly,  and  that  they  are  always  separated 
from  the  surface  of  the  tissues  by  a  tube  (Fig.  38). 
Avoid  placing  tubes  in  the  middle  of  a  mass  of  gauze 
(Fig.  39).  In  fractures  of  the  femur,  the  wound  can  be 
kept  open  by  short  pieces  of  rubber  tube  3  cms.  (about 


TECHNIQUE   OF  THE   STERILISATION     131 

I J  inches)  diameter,  which  are  separated  from  one 
another  by  other  pieces  of  tube  placed  at  right  angles. 
As  gravity  will  not  permit  fluid  to  remain  on  the  surface 
of  the  wound,  a  sufficient  number  of  tubes  is  arranged  so 
as  to  moisten  every  portion  of  the  wound  surface  (Fig.  38). 


Fig.  39. — The  same  ii-regular  wound  of  the  thigh.  The  tubes  are  wrongly 
placed.  Instead  of  being  in  contact  with  the  tissues  they  are  in  contact 
with  the  gauze  which  fills  the  wound. 

In  the  large  wound  of  a  compound  fracture  of  the  thigh 
at  least  8  or  10  tubes  are  needed. 

C.  Arrangement  of  the  Tubes  according  to  the  State 
of  Infection,  ist.  Fresh  Wounds. — Fresh  wounds  nearly 
always  bleed.  If  tubes  pierced  with  small  holes  be 
placed  in  a  wound  containing  fresh  blood,  the  tube  will 
be  filled  with  it,  the  blood  will  coagulate,  and  the  lumen 
of  the  tube  will  be  obliterated.     It  is  essential,  in  fresh 


/ 


133     TREATMENT   OF   INFECTED   WOUNDS 

wounds,  to  arrest  haemorrhage  thoroughly,  before  arrang- 
ing the  tubes,  and  to  verify  their  permeabiUty  with  care, 
before  continuing  the  dressing.  Fresh  wounds  having 
no  secretion,  or  very  little,  tubes  sheathed  in  absorbent 
fabric  may  be  applied  to  their  surface  without  incon- 
venience. For  the  same  reason,  gauze  is  less  harmful 
on  fresh  wounds  than  on  wounds  which  are  suppurating. 
2nd.  Suppurating  Wounds. — The  presence  of  pus  on  a 
wound  is  an  indication  that  tubes  surrounded  by  absor- 


FiG.   40. — Testing   the   permeability  of   a   conducting  tube  at   the  time   of 

dressing. 

bent  tissue  may  not  be  used,  because  this  fabric  immedi- 
ately becomes  saturated  with  pus.  For  the  same  reason 
"  wicks "  and  gauze  compresses  are  used  as  little  as 
possible,  and  tubes  multiplied.  Gauze  may  be  used  at 
the  orifice  of  the  wound.  But  all  the  diverticula  should 
contain  tubes  and  not  gauze.  It  is  advisable  to  have 
the  tubes  more  numerous  than  in  a  fresh  wound  of  the 
same  dimensions. 

D.  Testing   the   Working  of  the    Tubes. — Before  the 
dressing    is  applied,  the  permeability  of  the  tubes  and 


TFXHNIOUE    OF   THE    STERILISATION     133 

their  perforations  should  be  tested  (Fig.  40),  also  the 
manner  in  which  the  various  regions  of  the  wound  are 
receiving  their  share  of  the  antiseptic  Hquid.  This  test 
is  to  prove  that  the  tubes  have  not  become  plugged  with 
blood-clot,  and  that  the  distribution  is  taking  place 
evenly  over  the  whole  surface.  Further,  it  shows  what 
quantity  of  liquid  will  be  needed  to  fill  the  wound  com- 
pletely, or  to  moisten  the  entire  surface,  should  its 
position  not  allow  of  its  being  filled. 

The  nurse  should  be  present  at  this  testing,  which 
will  also  show  her  how  to  control  the  flow  of  liquid  in 
the  wound  without  wetting  the  patient. 


III.  Dressing 

1st.  Method  of  carrying  out  the  Dressing. — As  soon 
as  the  tubes  are  in  position,  gauze  compresses  soaked  in 
Dakin's  solution  are  applied.  These  compresses  help  to 
fix  the  tubes  on  the  surface  of  the  wound.  The  tubes 
have  been  selected  long  enough  to  allow  several  centi- 
metres of  their  non-perforated  portion  to  be  outside  the 
dressing  (Fig.  41).  Also  the  perforated  part  must  be 
buried  wholly  in  the  wound,  because  otherwise  the  free 
openings  would  allow  fluid  to  escape  unused,  possibly 
doing  harm. 

After  the  application  of  the  compresses  to  the  wound, 
the  adjoining  skin  is  protected  by  squares  of  gauze, 
sterilised  in  vaselin  (Fig.  41).  Pieces  8  or  10  cms. 
square  are  placed  in  yellow  vaselin  and  sterilised.  At 
the  moment  of  dressing,  they  are  taken  up  with  dressing 
forceps  and  applied  to  the  surface  of  the  skin,  to  which 
they    immediately    adhere.       They    form    an    excellent 


134     TREATMENT   OF   INFECTED   WOUNDS 


protection  for  the  skin,  which,  on  the  posterior  aspect  of 
the  trunk  or  Hmbs,  has  a  tendency  to  become  irritated 
by  the  hypochlorite. 


^^^^^^immmm^^:^^^^^^^- 


Fig.  41.— Dressing  :  «,  Conducting  tube  kept  in  the  wound  by  gauze  placed 
in  the  orifice  ;  /;,  Squares  of  gauze  sterilised  in  vaseline  placed  on  the 
skin  around  the  wound. 

The  dressing  is  completed  by  a  sheet  of  cotton-wool 
protected  on  either  surface  by  one  thickness  of  gauze. 


h  '      ii  ii;    ''-'li 


!       :■■'(:•••■' 

i  \ 


:  -    % 


1; 

\       I 


'.  I 


I       !    i,     ;     ! 


i'r'';  i,  ,.  ;  \  -I   I    !.  ,'i 


j('r,;!U,»4-!..,|f!W'TM?;lJ 
liii    I 


I'l         'I! 


1;     ;     •  I 


1  .<^-ii>„  -J- /.,... 


Fio.  42. — Sheets  of  dressings,  composed  of  layers  of  absorbent  cotton-wool, 
non-absorbent  cotton-wool,  and  gauze. 

This  dressing  is  prepared  beforehand  in  three  different 
sizes  (Fig.  42).     It  is  composed  of  four  strata  ;  a  layer 


TECHNIQUE   OF   THE   STERILISATION     135 

of  gauze,  a  sheet  of  absorbent  cotton-wool,  a  sheet  of 
non-absorbent  cotton-wool  {coton  carde),  and  a  final 
cover  of  gauze  (Fig.  43).  The  side  which  has  the 
absorbent    cotton-wool     is     applied    next    the    wound. 


F'iG.   43. — Section   of  the  sheet   of  dressing  :   A,  Gauze.     B,   Carded  (non- 
absorbent)  cotton-wool.     C,  Absorbent  cotton-wool.     D,  Gauze. 

Secretions  are  thus  absorbed,  without  being  able  to 
escape  readily  to  the  exterior,  by  reason  of  the  presence 
of  the  non-absorbent  cotton-wool.  At  the  same  time 
evaporation    goes   on    quite   easily  through   this  almost 


Fig.  44. — Dressing  applied  around  a  compound  fracture  of  the  leg,  and 
fastened  by  safety-pins  j  the  distributing  tube  is  fixed  to  the  plaster 
apparatus  by  safety-pins. 


waterproof  layer.     Waterproof  fabrics  should  never  be 
used. 

The  application  of  the  dressing  is  speedy.  The 
middle  part  of  the  dressing  is  placed  under  the  limb  and 
the  two  sides  are  fastened  on  the  anterior  surface  of  the 


136     TREATMENT   OF    INFECTED    WOUNDS 

limb  by  two  or  three  safety  pins.  The  use  of  a  bandage 
is  thus  avoided.  Besides,  the  dressing  is  easily  undone, 
and  the  wound  can  be  examined  and  the  position  of  the 
tubes  ascertained  without  disturbing  and  distressing  the 
patient.  When  the  dressing  is  first  applied,  two  scissor- 
cuts  are  made  in  the  layer  of  cotton-wool  to  allow  the 
rubber  tubes  to  emerge  readily  from  the  dressing 
(Figs.  35  and  45). 


Fig.  45. — Position  of  the  distributing  tube  on  the  svirface  of  the  dressing. 
The  conducting  tubes  penetrate  the  dressing,  either  at  the  point  where  the 
end  of  the  layer  of  cotton-wool  and  gauze  overlaps,  or  through  windows 
cut  with  scissors. 


2nd.  Fixation  of  Tubes  and  Cannulae. — When  the 
dressing  is  finished,  the  ends  of  the  supply-tubes  emerge 
at  different  points  from  the  layer  of  cotton-wool  and 
gauze.  These  tubes  are  connected  up  in  groups  of  two 
or  four  by  means  of  the  branched  unions  or  cannulae 
which  have  been  described  (Figs.  45  and  21).  In  the 
case  of  a  compound  fracture  of  the  thigh,  the  eight  tubes 
are  divided  into  two  groups  and  united  by  two  cannulae 
of  four  branches  each  (Fig.  46).  In  the  case  of  a  very 
extensive  wound  where  certain  of  the  small  conductino" 


TECHNIQUE   OF   THE    STERILISATION     137 

tubes  are  too  short  to  be  connected-up  with  the  branches 
of  the  cannula,  they  arc  lengthened  by  pieces  of  rubber 
tube  and  "  unions  "  or  connecting-tubes  of  glass  (Fig.  22). 
This  work  can  be  done  after  the  dressing,  when  the 
irrigating  apparatus  is  installed. 


l''ir,.  46.    -Arrangemfuit  on  the  surface  of  a  dressing  of  a  Y-connecting  lube, 
and  of  two  distributing  tubes  with  four  branches. 

After  the  tubes  have  been  joined  up  to  the  cannula, 
this  latter  is  fixed  to  the  highest  part  of  the  dressing. 
For  example,  in  a  compound  fracture  of  the  thigh,  the 
cannula  is  fixed  above  the  middle  of  the  anterior  aspect 


Fu,.  47. — Method  of  fixing  a  distributing  tube  to  the  surface  of  a  dressing. 

of  the  limb.  This  fixing  is  simply  done  by  nipping  the 
largest  part  of  the  glass  cannula  in  a  big  safety-pin,  itself 
attached  to  the  dressing.  Then  the  larger  end  of  the 
cannula  is  united  to  the  irrigating-tube  which  is  attached 
to  the  flask  or  other  reservoir   of  liquid.      The  correct 


138     TREATMENT   OF   INFECTED    WOUNDS 

fixing  of  the  cannula  to  the  surface  of  the  dressing  is 
important.  Thanks  to  it,  the  small  conducting  tubes  lie 
in  the  wound,  in  the  positions  in  which  they  have  been 
placed,  without  either  the  weight  of  the  irrigating  tube 
or  the  movements  of  the  patient  being  able  to  shift 
them. 

3rd.  Immobilisation  of  the  Limb. — Naturally  the  limb 
should  be  prevented  as  much  as  possible  from  moving. 
Either  plaster  apparatus,  suspension,  or  continuous  trac- 
tion will  be  used.  In  every  case  where  it  is  indicated, 
the  patient  is  placed  on  a  Bradford's  frame.  When  the 
time  for  dressing  comes,  the  frame  is  raised,  one  or  two 
bands  removed,  so  that  the  posterior  portion  of  the  limb 
or  trunk  can  be  examined  or  dressed  without  moving  the 
patient. 

The  dressing  is  renewed  every  twenty- four  hours.  If, 
however,  before  the  expiration  of  this  period,  the  cotton- 
wool has  become  very  wet,  the  outer  layer  of  the  dressing 
may  be  changed  without  disturbing  the  tubes  or  the  layer 
of  gauze  which  covers  the  wound.  The  changing  of 
the  dressing  consists  in  removing  the  gauze  compresses 
which  are  on  the  surface  of  the  wound,  and  at  the  entrance 
to  it.  The  position  of  the  tubes  is  carefully  checked, 
and  modified  if  there  should  be  need.  No  washing  is 
done,  simply  fresh  gauze  and  an  external  dressing 
applied.  The  manipulations  are  thus  extremely  simple, 
and,  in  a  short  time,  the  surgeon  can  personally  dress 
a  large  number  of  cases. 

The  mattress  is  protected  by  a  waterproof  sheet. 
The  quantity  of  liquid  used  should  be  always  so  small 
that  the  bed  is  not  flooded. 


TECHNIQUE   OF   THE    STERILISATION     139 

IV.  Instillation  of  the  Antiseptic  Liquid 

The  flask  holding  a  litre,  or  other  convenient  reser- 
voir, is  filled  with  Dakin's  solution,  coloured  to  a  rose- 
tint  with  permanganate  of  potassium.  This  coloration 
distinguishes  Dakin's  solution  from  physiological  saline 
solution,  and  most  assuredly  prevents  mistakes. 

1st.  Continuous  instillation  gives  better  results  than 
intermittent  instillation.  But  it  is  not  so  frequently 
employed.  In  fact,  it  is  only  suited  to  wounds  where 
the  liquid  can  remain  in  quantity,  or  to  small  wounds 
for  which  a  single  conducting  tube  sheathed  with 
absorbent  fabric  will  suffice.  The  flow  of  the  liquid 
is  regulated  by  means  of  a  screw  pinch-cock  inter- 
posed between  the  flask  and  the  drop-counter.  Five 
or  six  drops  per  minute  will  usually  give  sufficient 
moisture  to  this  type  of  wound.  It  should  be  remem- 
bered that  the  pressure  of  the  liquid  at  the  surface  of 
the  wound  is  represented  by  the  difl'erence  in  level 
between  the  wound  and  the  lower  portion  of  the  drop- 
counter,  and  not  between  the  wound  and  the  upper 
portion  of  the  reservoir.  If  the  drop-counter  be  placed 
too  low,  on  a  level  with  the  wound,  it  will  not  work. 
It  is  equally  necessary  to  be  aware  that  drop-by-drop 
instillation  should  only  be  used  when  the  end  of  the 
irrigating  tube  is  connected  up  with  only  one  of  the 
little  tubes  which  distribute  liquid  to  the  wound.  Under 
these  conditions,  continuous  instillation  permits  the 
degree  of  concentration  of  the  antiseptic  liquid  on  the 
surface  of  the  wound  to  be  maintained  under  better 
conditions  than  intermittent  instillation. 

2nd.  Intermittent  instillation  is  used  for  the  greater 


140     TREATMENT   OE    INEECTED    WOUNDS 

number  of  wounds.  As  a  matter  of  fact,  the  great 
majority  of  wounds  are  extensive  and  irregular  and  have 
several  openings.  To  these  continuous  instillation  is  not 
suited. 

Intermittent  instillation  is  carried  out  by  releasing 
for  a  few  seconds,  every  two  hours,  the  pinch-cock  which 
is  placed  on  the  irrigating  tube  just  below  the  reservoir. 
Liquid  immediately  escapes  from  the  flask  (irrigating- 
bottle  or  reservoir),  and  spurts  out  in  great  abundance 
from  every  hole  of  all  the  conducting  tubes.  The  dura- 
tion of  flow  of  the  liquid  should  be  very  short,  lest  the 
patient  be  flooded  out.  The  (quantity  thus  injected 
varies,  according  to  the  nature  of  the  case,  from  20  to 
100  c.c.^  and  sometimes  more.  As  a  general  rule,  the 
injections  are  made  every  two  hours  ;  occasionally,  with 
greater  frequency.  When  the  apparatus  is  installed  as 
we  have  described,  the  work  of  the  nurse  in  charge 
of  the  instillations  is  very  light.  In  fact,  as  in  each 
case  she  halts  at  the  foot  of  the  bed,  she  has  only  to 
press  for  a  few  seconds  the  spring  "  pince  de  Mohr " 
fixed  on  the  irrigating  tube. 

The  total  quantity  of  liquid  injected  in  24  hours  varies 
from  about  250  to  1200  c.c.^  In  very  extensive  wounds, 
more  can  be  injected  without  inconvenience.  The  only 
fixed  rule  is,  that  the  wound  should  be  kept  constantly 
moistened  by  the  liquid,  without  the  patient  being  made 
uncomfortably  damp. 

4th.  In  intermittent  instillation,  the  pressure  varies 
from  forty  centimetres  to  a  metre.  It  should  be  regu- 
lated according  to  the  particular  needs  of  the  wound  and 

'  Say  from  f  oz.  to  33  oz. 

-'   Roughly,  eight  ounces  to  two  pints. 


TECHNIQUE   OE   THE   STERILISATION     141 

the  sensitiveness  of  the  patient.  At  the  moment  of 
commencing  the  instillation,  he  experiences  sometimes 
a  slight  impression  of  pain  which  may  last  some  minutes. 
Sometimes,  again,  he  has  only  a  sensation  of  chilliness, 
or  actual  cold.  The  patient  should  never  suffer  actual 
pain  from  the  instillation.  Should  he  complain,  it  shows 
that  an  error  of  technique  has  been  committed.  The 
pain  may  be  due  to  excess  of  pressure,  or  to  the  wound- 
opening  being  too  small.  If  the  pressure  be  too  great, 
the  liquid  spurts  out  violently  from  the  apertures  in  the 
tubes  against  the  walls  of  the  wounds  and  bruises  the 
tissues.  That  is  why  the  pressure  should  never  be 
greater  than  one  metre.  With  sensitive  patients,  a 
pressure  of  20  to  30  centimetres  is  sufficient.  Another 
cause  of  pain  is  retention  of  the  liquid  in  the  wound 
under  pressure.  If  the  incisions  are  too  limited,  and  if  the 
conducting  tubes  are  too  tightly  gripped  by  the  tissues 
or  by  compresses,  the  liquid  cannot  escape  freely  from 
the  wound.  It  accumulates  under  pressure,  and  the 
patient  feels  it.  The  wound  should  be  freely  opened 
up,  so  that  the  liquid  may  escape  without  hindrance. 

V.  Duration  of  the  Instillation 

Instillation  of  liquid  continues  day  and  night  until 
all  microbes  have  disappeared  from  the  "  smears." 
Therefore  it  is  inspection  of  the  microbial  curves  which 
indicates  when  the  irrigation  can  be  stopped.  So  long 
as  a  few  microbes  remain,  no  alteration  should  be  made 
either  in  the  quantity  of  the  liquid  or  in  the  frequency  of 
the  instillations.  So  long  as  a  focus  of  infection,  be  it 
ever  so  small,  remain  on  the  surface  of  the  wound,  total 


142     TREATMENT   OF    INFECTED   WOUNDS 

reinfection  is  possible.  If  the  instillations  be  stopped,  or 
their  frequency  lessened,  when  the  microbial  curve  shows 
only  one  or  two  microbes  per  field  of  the  microscope, 
rapid  reinfection  may  be  brought  about.  On  the  other 
hand,  the  presence  of  hypochlorite  does  not  lessen  the 
rapidity  of  repair.  By  suppressing  microbes,  it  accele- 
rates it.  As  the  few  small  infected  foci  which  still 
persist  on  the  wound  after  some  days  of  instillation, 
cannot  enlarge,  the  greater  part  of  the  wound  cicatrises 
with  the  same  speed  as  if  it  were  aseptic. 

In  general,  from  three  to  ten  days  are  needed  to 
sterilise  a  wound  of  the  soft  parts  and  fifteen  days  or 
more  for  a  compound  fracture.  These  figures  are  those 
observed  when  the  wound  is  sterilised  before  the  sup- 
puration stage.  But  if  the  treatment  is  commenced 
after  the  wound  has  already  suppurated,  the  duration 
of  the  instillation  period  is  usually  much  longer.  Bac- 
teriological examination  alone  can  indicate  the  time 
when  the  instillations  may  be  discontinued. 


VI.  Errors  of  Technique 

A.  Insufficient  Penetration  of  the  Liquid. — Whenever 
examination  of  the  curve  of  sterilisation  shows  that, 
before  attaining  surgical  asepsis,  the  line  has  become 
horizontal,  we  may  be  sure  that  a  fault  in  technique  has 
been  committed.  We  know,  in  fact,  that  the  diminution 
in  the  number  of  microbes  in  a  wound  should  progress 
steadily,  whenever  the  antiseptic  liquid  is  carried  into 
all  regions  infected.  If  sterilisation  is  not  achieved, 
in    the    first    place    it    is    necessary   to    ascertain    that 


TECHNIQUE   OF   THE   STERILISATION     143 

the  Dakin's  solution  contains  the  needful  amount  of 
hypochlorite,  and  afterwards  look  into  the  possible 
causes  which  could  hinder  the  penetration  of  the  liquid 
throughout  the  wound.  The  causes  are  generally  as 
follows  :— 

1st.  The  distribution  of  the  liquid  in  the  wound  has 
not  been  completely  accomplished,  by  reason  of : 
{a)  slipping  or  detachment  of  one  of  the  conducting 
tubes  ;  {b)  obliteration  of  the  lumen  of  a  tube  by  blood- 
clot  ;  {c)  kinking  in  a  tube,  due  to  faulty  placing  ;  {d)  the 
omission  to  put  a  conducting  tube  in  some  diverticulum 
of  the  wound.  Should  a  tube  be  placed  in  a  passage  too 
narrow  which  it  fits  tightly,  there  can  be  no  return  flow 
of  liquid  between  the  wall  of  the  tube  and  that  of  the 
wound,  and,  in  consequence,  no  instillation.  Careful 
examination  of  the  wound  will  enable  us  to  ascertain 
the  presence  of  one  or  more  of  these  causes  of  error. 

2nd.  There  is  some  error  in  the  installation  of  the 
irrigating  apparatus.  The  fault  most  frequently  com- 
mitted is  that  of  putting  a  drop-counting  appliance  in 
communication  with  several  tubes.  As  the  output  is 
very  small,  the  liquid,  obeying  the  dictates  of  gravity, 
runs  down  one  of  the  tubes  while  nothing  goes  to  the 
rest.  The  same  thing  may  happen  in  intermittent 
irrigation,  if  the  calibre  of  the  principal  tube  or  the 
inferior  orifice  of  the  flask  (reservoir)  is  too  narrow.  In 
this  case  the  outflow  is  insignificant,  and  instead  of  the 
liquid  being  distributed  to  four  or  eight  tubes,  it  passes 
along  only  a  few  of  them,  and,  in  consequence,  a  whole 
region  of  the  wound  is  deprived  of  liquid.  This  mistake 
will  be  avoided  if  the  instructions  we  have  given  (p.  121), 
on  the  subject  of  the   relative  calibres  of  the  different 


144     TREATMENT   OF    INFECTED   WOUNDS 

tubes  and  the  installation  of  the  irrigation  apparatus  be 
followed  precisely. 

3rd.  The  quantity  of  liquid  is  insufficient.  Inade- 
quate instillation  is  most  frequently  seen,  when,  instead 
of  using  irrigating  apparatus,  a  syringe  is  employed. 
As  the  tubes  are  multiple,  the  nurse  has  to  spend  much 
time  in  injecting  the  needed  amount  with  a  syringe. 
Therefore,  whenever  this  method  is  in  use,  the  quantity 
of  antiseptic  is  frequently  found  to  be  insufficient.  The 
same  thing  happens  in  using  irrigation  apparatus, 
when,  through  negligence,  the  irrigations  are  omitted, 
or  made  at  too  long  intervals  during  the  night.  Like- 
wise when  a  tube  passed  into  too  narrow  a  track 
blocks  up  its  lumen,  so  that  no  circulation  is  estab- 
lished (Fig.  48).  By  carefully  examining  a  wound  we 
find  indications  which  lead  us  to  suspect  the  insuffi- 
ciency in  quantity  of  liquid.  Two  symptoms  present 
themselves  in  these  cases.  One  is,  the  pus  beginning 
to  have  an  unpleasant  odour,  for  a  well-irrigated  wound 
should  be  perfectly  inodorous.  The  second  is  absence 
of  the  characteristic  changes  in  the  secretions.  The  dis- 
charge from  a  well-irrigated  wound  should  be  thicker 
and  more  transparent  than  the  normal  secretion.  The 
presence  of  unmodified  secretions  in  a  wound  permits 
one  to  assert,  that,  either  the  liquid  does  not  contain  the 
sufficient  amount  of  hypochlorite,  or  that  the  instillation 
is  not  being  carried  out  in  the  prescribed  manner. 

B.  Excessive  Quantity  of  Liquid. — When  the  liquid 
is  allowed  to  flow  too  long  over  the  surface  of  a  wound, 
or  in  quantity  too  abundant,  the  absorbent  cotton- 
wool of  the  dressing,  and  evaporation,  are  not  equal  to 
the    task   of  settinp^   rid  of   the   excess  of  fluid.      The 


^^'•^"'fc. 


TECHNIQUE    OF   THE    STERILISATION     145 

bed  becomes  flooded,  the  limb  bathed  in  Dakin's  solu- 
tion, and  the  skin  becomes  irritated.  An  excessive 
quantity  of  liquid  has  no  deleterious  action  on  the 
wound,  but  it  worries  the  patient.  He  is  in  an  uncom- 
fortable plight,  and  ulceration  of  the  skin,  more  or  less 


Fig.  48. — Relative  dimensions  of  the  orifice  of  the  wound  and  of  the  conduct- 
ing lube,  a,  Faulty  arrangement. — The  opening  is  much  too  small,  the 
liquid  is  under  pressure  in  the  limb,  and  its  circulation  is  impossible. 
h,  Correct  arra^igement. — The  opening  is  large  enough  to  allow  the  free 
return  of  the  liquid  between  the  wall  of  the  wound  and  the  outside  of  the 
tube. 


painful,  may  be  produced.  Therefore  the  nurse  must 
learn  how  to  regulate  the  quantity  of  liquid  so  that  the 
wounds  are  sufficiently  moistened  without  the  patient 
being  made  damp.  With  a  little  attention  nurses  soon 
avoid  injecting  too  much  liquid  into  the  wound.     Besides, 

10 


146    TREATMENT   OF   INFECTED   WOUNDS 

it  is  always  better  to  use  too  much  than  too  Httle,  for 
the  inconvenient  results  of  too  much  liquid  are  not 
serious  and  can  be  remedied  easily.  By  applying  care- 
fully squares  of  vaselined  gauze  (p.  133)  to  the  skin 
about  the  wound,  it  can  be  protected  completely  against 
the  lesions  produced  by  an  excess  of  liquid. 

C.  Excessive  Pressure. — We  have  noticed  already  that 
an  excess  of  pressure  may  be  due  to  two  quite  different 
causes — a  too  great  elevation  of  the  reservoir  of  fluid 
above  the  level  of  the  bed,  or  to  smallness  of  the  incision 
which  hinders  a  ready  reflux  of  the  liquid  between  the 
walls  of  the  wound  and  the  conducting  tube  (Fig.  48). 
Excessive  pressure  of  liquid  in  the  wound  brings  about 
distress.  The  moment  instillation  gives  rise  to  pain  in 
a  case,  it  must  be  discontinued,  and  the  mistake  in 
technique  discovered,  which  is  the  cause. 


CHAPTER  V 

CLINICAL    AND     BACTERIOLOGICAL     EXAMINATION 

OF    WOUNDS 

Every  infected  wound  should  respond  to  chemio-therapy, 
when  this  is  applied  in  correct  manner.  It  is  necessary, 
therefore,  that  the  progress  of  treatment  should  be  con- 
trolled each  day  by  examination  of  the  wound,  and  that 
the  technique  should  be  modified  according  to  the  results 
of  this  examination.  Clinical  and  bacteriological  study 
of  the  wounded  patient,  and  of  the  wound,  is  the 
indispensable  guide  in  therapeusis. 

I.  Clinical  Examination 

The  aspect  presented  by  wounds  is  modified  under 
the  influence  of  treatment  in  a  manner  more  or  less  rapid 
according  to  the  nature  and  age  of  the  lesion.  This 
evolution  varies  according  to  the  period  of  infection 
during  which  sterilisation  was  commenced. 

A.  Modificatioiis  of  the  Local  Conditions,  ist.  Fresh 
Wounds. — Immediately  after  the  infliction  of  the  injury, 
blood  pours  out  between  the  edges  of  the  wound  and  forms 
a  clot.  Up  to  the  sixth  or  twelfth  hour,  there  is  not,  as 
a  general  rale,  either  swelling  of  the  tissues  or  secretion 

147 


148     TREATMENT   OF    INFECTED   WOUNDS 

on  the  surface.  At  the  same  time  we  have  sometimes 
met  with  wounds  only  six  hours  old  containing  gas  and 
giving  off  a  putrefactive  odour.  Towards  the  twenty- 
fourth  hour  wounds  secrete  slightly.  When  instillation 
is  begun  between  the  sixth  and  the  twelfth  hour,  the 
tissues  retain  their  normal  appearance.  Muscles  remain 
red  and  cellular  tissue  is  not  changed.  If  the  tissues 
have  been  severely  bruised  they  necrose,  but  neither 
redness  nor  swelling  is  seen  at  the  margin  of  the  wound. 
At  the  end  of  three  or  four  days  the  necrosed  tissue 
becomes  of  whitish  colour  and  soft  consistence.  It 
begins  to  become  detached  in  fragments  from  the 
deep  parts.  Red  portions  begin  to  show  themselves. 
Towards  the  eighth  day  following  the  injury,  the 
wound  is  usually  clean.  The  surface  is  of  a  bright  red. 
Secretions  are  almost  nil.  The  margins  of  the  wound 
are  not  swollen  and  present  no  evidence  of  lymphangitis. 
Should  signs  of  inflammation  appear,  it  is  certain  that 
a  fault  in  technique  has  been  committed,  either  in  the 
manufacture  of  the  liquid,  or  the  disposition  of  the 
instillation  tubes.  Towards  the  tenth  day,  the  entire 
surface  of  the  wound  is  even  and  red.  In  the  most 
irregular  portions,  and  by  the  lymphatics  of  vasculo- 
nervous  bundles,  sometimes  a  few  drops  of  pus  may  be 
seen.  The  limb  has  regained  its  normal  size.  The 
integuments  about  the  wound  are  supple  and  not  tender 
on  pressure.  The  skin  is  not  yet  adherent  to  the  deep 
parts.  That  is  the  reason  why,  wherever  possible, 
wounds  should  be  closed  before  the  twelfth  day. 

The  integuments  are  sometimes  modified,  after  the 
lapse  of  a  few  days,  by  the  application  of  Dakin's  solu- 
tion.    They  become  red  and  painful.     This  complication 


CLINICAL   EXAMINATION  149 

may  be  due  to  one  of  several  causes.  The  tincture 
of  iodine  vvhicli  has  already  irritated  the  skin  is 
generally  the  cause.  But  the  Dakin's  solution  may 
have  been  badly  made.  If  Dakin's  solution  con- 
tains too  much  alkali,  it  becomes  as  dangerous  as  eau 
de  Javel  or  Labarraque's  liquor.  The  moment  irri- 
tation of  the  skin  occurs,  the  solution  should  be  ex- 
amined to  see  if  it  fulfils  the  conditions  laid  down  by 
Dakin.  It  sometimes  happens  that  a  solution  perfectly 
prepared  may  cause  redness  in  subjects  who  have  an 
exceptionally  delicate  skin,  or  when  the  wound  occupies 
the  posterior  aspect  of  the  trunk,  the  pelvis,  or  the  limbs  ; 
or  when  the  dressings  are  too  tightly  applied,  or  changed 
too  infrequently.  The  best  way  to  avoid  irritation  of 
the  integuments  about  a  wound  is  to  cover  the  skin  with 
squares  of  gauze  sterilised  in  yellow  vaselin.  If  the 
wound  is  on  a  limb,  it  is  useful  to  employ  American 
suspension  apparatus  If  the  trunk  or  pelvis  be  affected, 
the  patient  should  be  placed  bodily  upon  a  Bradford's 
frame.  Irritation  of  the  skin  due  to  Dakin's  solution  is 
very  rare,  and  is  easily  distinguished  from  the  lym- 
phangitis so  frequent  in  wounds  treated  aseptically. 

Towards  the  twelfth  day,  granulations  begin  to  cover 
the  wound  at  the  same  time  as  the  epithelial  margin 
develops.  The  skin  becomes  adherent  to  the  subjacent 
parts.  The  whole  surface  of  the  wound  is  composed  of 
rose-tinted  granulations.  Cicatrisation  comes  about  in 
a  regular  manner,  without  any  interval  of  retrogression, 
such  as  one  is  accustomed  to  in  wounds  treated  by  the 
aseptic  method.  The  cicatrisation  curve  develops  sym- 
metrically, following  the  algebraic  formula  of  Lecomte 
du  Nouy. 


ISO     TREATMENT   OF    INFECTED   WOUNDS 

The  secretions  of  wounds  thus  treated  are  not  very 
abundant,  especially  when  pains  have  been  taken  care- 
fully to  resect  contused  tissues.  At  the  beginning,  the 
compresses  are  covered  with  a  thick  greyish  secretion, 
resulting  from  the  combination  of  pus  and  hypochlorite. 
Then,  little  by  little,  the  secretion  becomes  more  sticky, 
clearer,  and  at  last,  colourless.  At  this  stage,  it  is  probable 
that  sterilisation  has  been  attained. 

2nd.  Gangrenous  and  Phlegmonous  Wounds. — When 
wounds  have  reached  the  stage  of  inflammation  by 
the  time  the  treatment  is  commenced,  the  clinical 
modifications  which  they  undergo  under  the  influence 
of  sterilisation  are  less  rapid.  If  the  liquid  can  reach 
all  the  infected  regions,  redness,  swelling,  and  pain 
diminish  at  the  end  of  one  or  two  days.  But  if  the 
lesions  cannot  be  reached,  even  at  the  price  of  free 
incisions,  results  of  treatment  are  negative.  In  a  general 
way,  when  tubes  have  been  placed  in  all  the  infected 
regions,  the  wound  takes  on  the  appearance  previously  de- 
scribed at  the  end  of  a  few  days.  When  the  tubes  have 
not  been  able  to  reach  all  the  infected  regions,  but  when 
a  great  portion  of  the  wound  has  become  sterile  under  the 
influence  of  the  treatment,  the  septic  regions  situate  be- 
yond the  reach  of  the  liquid  accelerate  their  spontaneous 
disinfection.  It  would  appear  that,  the  volume  of  infection 
being  lessened,  the  organism  defends  itself  more  readily. 

In  all  the  cases  where  incisions  facilitate  the  penetra- 
tion of  the  antiseptic  into  gangrenous  foci,  gas  and  odour 
are  the  first  to  disappear,  then  the  necrosed  tissues 
dissolve.  They  are  eliminated  after  the  lapse  of  a  few 
days,  without  the  margins  of  the  wound  presenting  any 
inflammatory  reaction. 


CLINICAL   EXAMINATION  151 

It  is  important  to  notice  the  rapid  disappearance  of 
pain  in  these  cases  of  infected  wounds.  As  soon  as 
Dakin's  solution  has  got  rid  of  the  infiltration  of  the 
tissues,  the  dressings  cease  to  be  painful.  Wounded 
men  whose  wounds  are  sterile  do  not  suffer. 

5th.  Suppurating  Wounds. — In  wounds  of  long  stand- 
ing, which  are  already  freely  suppurating  when  the 
antiseptic  treatment  is  begun,  the  earliest  sign  of  the 
action  of  the  antiseptic  is  a  characteristic  change  in 
the  pus.  This  takes  on  a  viscous  consistency,  while  its 
colour  becomes  yellowish,  transparent.  In  a  few  days  it 
lessens  in  quantity,  then  disappears.  Granulations  change 
their  aspect  and  become  red  and  even.  If,  the  technique 
being  correct,  these  modifications  do  not  present  them- 
selves, it  is  certain  that  in  the  depths  of  the  wound  there 
exists  a  foreign  body. 

In  wounds  of  the  soft  parts,  suppuration  disappears 
completely  at  the  end  of  two  or  three  days.  A  little 
thick  transparent  liquid  still  remains  on  the  surface 
of  the  wound  after  it  has  become  surgically  sterile.  In 
compound  fractures,  suppuration  continues  so  long  as 
the  liquid  is  not  introduced  into  all  the  cavities  where 
microbes  are  found.  If  suppuration  remains  stationary, 
it  is  certain  that  there  is  a  sequestrum,  or  an  infundi- 
bulum  where  the  liquid  is  not  penetrating.  Without 
further  delay,  the  necrosed  splinters  should  be  removed, 
and  the  wounds  placed  under  conditions  which  will  allow 
the  liquid  to  penetrate  everywhere. 

B.  Modifications  of  the  General  Condition.  At  the 
outset  of  the  evolution  of  fresh  shell  and  bomb  wounds, 
fever  persists  for  several  days.  Frequently,  beginning  at 
the  third  or  fourth  day,  the  temperature  drops,  little  by 


152   tr?:atment  of  infected  wounds 

little  ;  sometimes,  in  deep  irregular  wounds,  it  may  keep 
up  longer.  When  the  tubes  are  well  placed  and  the 
instillation  of  the  antiseptic  is  adequate  over  the  whole 
surface  of  the  wound,  a  dissociation  or  want  of  relation 
between  the  temperature  and  the  other  signs  of  infec- 
tion is  produced.  Often  cases  are  seen  with  an  elevated 
temperature,  but  without  the  general  signs  of  intoxica- 
tion. They  eat  and  sleep  in  almost  normal  fashion. 
The  tongue  is  pink  and  moist.  They  are  calm,  complain 
of  no  pain,  and  do  not  look  like  sick  men.  This  con- 
dition may  be  attributed  to  the  destruction  by  the  hypo- 
chlorite of  the  substances  which  produce  the  general 
symptoms  of  infection,  or  to  a  considerable  diminution 
in  the  volume  of  infection.  In  these  cases  the  infection 
manifests  itself  only  in  the  high  temperature. 

The  persistence  of  pyrexia  amongst  cases  whose 
wounds  are  in  a  fair  way  of  sterilisation  is  due,  generally, 
to  the  presence  of  a  small  diverticulum  where  the  liquid 
is  not  penetrating.  In  fresh  compound  fractures  the 
wound  surface  may  be  protected  against  the  antiseptic 
by  necrosed  tissue,  by  a  compress,  or  by  a  blood-clot. 
As  a  consequence,  infection  develops  and  persists  in  the 
region  which  is  in  this  manner  withdrawn  from  the  action 
of  the  antiseptic.  It  may  happen  also  that  the  tubes 
are  not  placed  deep  enough,  or  that  the  liquid  is  not 
distributed  over  the  whole  surface  of  the  wound.  Almost 
the  whole  of  the  wound  is  sterilised,  but  at  the  point  not 
irrigated  infection  continues.  Hut,  usually,  this  infection 
is  too  slight  to  give  the  patient  the  appearance  of  a  sick 
man.  There  is  a  profound  difference  between  the  facial 
appearance  of  a  patient  whose  wounds  are  in  a  fair  way 
for  sterilisation,  even  if  he  still  has  some  fever,  and  the 


CLINICAL   EXAMINATION  153 

"  look "  of  a  man  whose  wounds,  treated  aseptically, 
are  still  suppurating.  In  suppurating  cases,  even  when 
the  wounds  are  well  drained  and  the  temperature  but 
slightly  raised,  frequently  the  general  signs  of  septic 
intoxication  are  found.  These  men  do  not  sleep. 
Appetite  is  gone  and  the  tongue  is  dirty.  They  are  at 
the  same  time  agitated  and  depressed,  and  they  are  in 
pain.  The  complexion  is  leaden.  In  a  word,  they  are 
sick  men.  Immediately  these  cases  are  treated  by  the 
antiseptic  method  and  suppuration  begins  to  lessen,  the 
general  condition  changes.  After  a  short  time  they  take 
on  the  appearance  of  cases  whose  wounds  are  sterile. 

Very  rarely,  there  are  cases  in  which  septicaemia 
develops  at  the  same  time  as  the  wound  is  becoming 
sterile.  We  have  seen  a  case  die  of  staphylococcal  septi- 
caemia, while  the  fractured  thigh  from  which  he  suffered 
was  in  excellent  condition.  Staphylococci  had  invaded 
the  circulation  before  sterilisation  had  had  time  to  be- 
come effectual.  But,  happily,  experience  has  shown  that 
septicaemia  is  exceptional  when  the  cases  are  suitably 
treated. 

C.  Value  of  Clinical  Observation. — Clinical  observation 
allows  one  to  presume  what  may  be  the  state  of  the 
wound,  but  it  yields  no  certainty.  In  fact,  wounds 
whose  margins  present  neither  oedema  nor  redness,  whose 
surface  is  covered  with  even  granulations  and  whose 
secretion  is  of  the  slightest,  may  still  be  strongly  in- 
fected. The  following  case  is  an  example  of  this.  After 
section  of  the  deep  femoral  by  a  shell-wound,  a  free 
incision  had  exposed  the  sheath  of  the  sciatic  nerve, 
which  was  filled  with  blood.  After  a  few  days  this  ex- 
tensive wound  had  an  excellent  appearance.     The  man 


154     TREATMENT   OF    INFECTED   WOUNDS 

was  in  no  pain,  and  had  no  pyrexia.  A  little  lemon- 
coloured  serum  flowed  from  the  wound.  It  was  collected 
in  a  pipette.  But  the  general  appearance  of  the  wound 
was  so  favourable  that  it  was  closed  with  strapping,  with- 
out waiting  for  the  results  of  the  bacteriological  examina- 
tion. That  evening  the  case  had  a  temperature  of  40°  C. 
(nearly  104°  Fahr.),  and  the  wound  had  to  be  taken  down. 
The  surgeon  then  asked  for  the  bacteriological  report, 
and  learned  that  the  transparent  liquid  contained  chains 
of  streptococci.  Hence  in  certain  cases  clinical  observa- 
tion is  absolutely  impotent  to  instruct  us  as  to  the  real 
condition  of  a  wound. 

Wounds  also  are  met  with,  covered  with  greyish 
granulations  and  with  a  puriform  liquid,  which  are 
aseptic,  and  which  may  be  sutured  with  success. 

Clinical  observation  should  be  looked  upon  as  an 
adjunct  to  the  bacteriological  examination.  Wounds 
identical  in  appearance,  from  the  clinical  point  of  view, 
may  be  in  very  different  microbial  conditions.  Between 
a  wound  which  yields  five  or  six  microbes  per  field 
of  the  microscope,  and  a  wound  which  contains  none, 
usually  there  is  no  appreciable  clinical  difference.  All 
the  same,  the  few  microbes  which  remain  on  the  surface 
of  the  first  wound  can  retard  by  one-half  the  rapidity 
of  its  cicatrisation.  The  presence  of  these  microbes  is 
important,  for  it  prevents  one  suturing.  Hence  the  aid 
of  the  laboratory  is  needed  constantly  to  ascertain  the 
progress  of  sterilisation. 


BACTERIOLOGICAL   EXAMINATION     155 


II.  Bacteriological  Examination 

The  object  of  the  bacteriological  examination  is  to 
demonstrate  the  progress  of  sterilisation  and  to  mark 
the  moment  at  which  this  sterilisation  is  advanced  suffi- 
ciently to  allow  of  effectual  closing  of  the  wound.  It  is 
necessary  that  the  quantity  of  microbes  contained  in  the 
wound  should  be  known.  Since  wounds  should  be 
examined  every  two  or  three  days,  and  as  in  most 
hospitals  there  is  no  bacteriological  specialist,  the 
technique  has  been  made  so  simple  that  a  large  number 
of  examinations  can  be  made  by  those  possessing  little 
experience  in  bacteriology.  The  secretions  of  the 
wounds  are  studied  by  means  of  "  smears."  This  sum- 
mary proceeding  allows  certain  qualitative  reports  to  be 
made,  but,  more  important,  it  allows  of  an  approximate 
enumeration  of  the  microbes  contained  in  the  secretions. 
Thanks  to  it,  the  diminution  in  the  numbers  of  the 
microbes  can  be  made  known  as  the  treatment  pro- 
gresses, up  to  the  date  of  their  total  disappearance.  We 
have  determined  empirically  that  the  disappearance  of 
microbes  from  the  smears  indicates  a  degree  of  asepsis 
compatible  with  closure  of  the  wound.  In  spite  of  its 
crudeness,  this  method  is  to  be  preferred  to  the  usual 
procedure  of  bacteriology.  In  truth,  "  smears "  show 
what  the  wound  contains,  while  cultures  indicate  what 
may  grow  under  certain  conditions.  Cultures  must  be 
relied  upon  if  it  is  desired  to  learn  if  a  wound  is 
bacteriologically  sterile,  or  when  it  is  important  to  know 
not  only  the  volume  but  the  nature  of  the  infection. 
The  culture  method  may  also  be  used  in  that  stage  of 


156     TREATMENT   OF    INFECTED    WOUNDS 

infection  in  which  smears  do  not  give  reliable  informa- 
tion, that  is  to  say,  during  the  first  twelve  hours.  At 
this  period,  in  fact,  microbes  are  in  such  small  numbers 
and  so  diluted  by  the  blood,  that  they  cannot  be  seen  in 
the  smears. 

A.  Technique,  ist.  Method  of  taking  Specimens  of  the 
Secretions. — During  the  first  six  or  twelve  hours  secretions 
are  absent  from  the  wound.  The  walls  bleed  more  or 
less  freely,  and  smears  of  blood  taken  from  the  wound 
show  no  microbes.  Specimens  should  be  taken  from  the 
parts  of  the  wound  which  are  not  bleeding,  in  the  neigh- 
bourhood of,  or  from  the  surface  of,  shreds  of  clothing  or 
shell  splinters. 

Wounds  older  than  twelve  hours  usually  have  some 
secretion.  As  the  haemorrhage  is  arrested,  secretions 
can  be  taken  easily  from  a  region  where  the  secretions 
are  not  diluted  by  blood.  Always  the  points  chosen  are 
in  contact  with  shreds  of  clothing  or  bits  of  shell,  for  in 
these  regions  the  primary  infection  is  to  be  found  at  its 
maximum. 

The  specimen  is  taken  by  means  of  a  rigid  platinum 
wire  mounted  on  the  end  of  a  glass  rod  (Fig.  49). 
Should  the  wound  be  undergoing  continuous  instillation, 
the  treatment  must  be  interrupted  for  two  hours  at  least, 
before  the  time  when  the  specimen  is  to  be  taken,  in 
order  that  the  secretions  may  not  be  diluted  by  hypo- 
chlorite. The  tubes  are  withdrawn  and  the  compresses 
removed  with  the  greatest  gentleness,  in  order  not  to 
provoke  haemorrhage.  The  spot  from  which  the  speci- 
men is  to  be  taken  is  chosen  with  minute  care.  It  must 
never  be  taken  from  a  region  of  the  wound  which  is 
bleeding.     That  region  is  sought  for  where  there  is  the 


BACTERIOLOGICAL   EXAMINATION     157 

greatest  probability  of  finding  microbes.  As  the  smooth 
surface  of  muscle  is  very  quickly  disinfected,  for  pre- 
ference one  examines  the  greyish  structures  which  are 
found  in  the  deepest  parts  of  wounds,  necrosed  points 
of  fascia,  the  surface  of  damaged  bone  or  the  culs-de-sac 
of  irregular  wounds,  where  secretions  can  accumulate 
protected  from  the  antiseptic  liquid.     It  is  by  means  of 


Fig.  49. — Taking  a  specimen. 


multiple  specimens  taken  from  various  parts  that  one 
can  ascertain  the  bacteriological  condition  of  a  wound. 
In  surface  wounds,  it  is  useful  to  examine  the  neigh- 
bouring skin.  With  the  aid  of  a  bistoury  or  a  rigid 
platinum  wire  the  surface  of  the  skin  or  the  epithelial 
border  is  lightly  scraped. 

2nd.  Preparation  of   the  Slides. — The  secretions  thus 
collected  are  spread  out  on  microscope  slides  (Fig.  50), 


158     TREATMENT   OF   INFECTED   WOUNDS 

which  are  furnished  with  a  label  upon  which  are  written 
the  name  of  the  patient,  his  number,  the  character  of  the 
wound,  and  the  region  of  the  wound  whence  the  secretion 
was  taken.  The  slides,  thus  prepared  during  the  course 
of  a  round  of  visits,  are  arranged  in  a  box  for  microscope 
specimens,  where  they  dry,  and  are  taken  to  the 
laboratory,  where  a  nurse  fixes  and  stains  them. 

Each  slide   is  held  between  the  thumb  and   index- 
finger,  and  passed  three  times  through  the  flame  of  a 


Fig.  50. — Making  a  "  smear." 


Bunsen  burner,  the  smear  being  turned  towards  the 
flame. 

Then  it  is  placed  on  a  glass  support  and  receives  a 
few  drops  of  carbolised  thionin.  After  half  a  minute, 
it  is  washed  with  water  and  put  aside  to  dry. 

3rd.  Counting'  the  Microbes. — The  slides  thus  stained 
are  arranged  upon  a  table,  and  the  nurse  places  on  each 
smear  a  drop  of  oil  of  cedar.  The  preparations  are  then 
examined  with  a  No.  12  immersion  objective  and  a 
No.  3  eyepiece.     The  number  of  microbes  found   in  a 


BACTERIOLOGICAL   EXAMINATION     159 

field  of  the  microscope  are  counted,  and  the  anatomical 
elements  which  are  found  there  are  also  scrutinised. 
This  technique  gives  naturally  only  crude  results,  but 
they  are  adequate.  In  fact,  when  the  number  of 
microbes  per  microscope-field  exceeds  fifty  or  a  hundred, 
it  is  useless  to  count  them  more  precisely.  The  exami- 
nation of  the  smears  has  but  one  object,  to  indicate  the 
progress  of  treatment.  Hence  it  is  easy  to  note  that  a 
secretion,  one  day  containing  innumerable  microbes,  shows 
the  next  day  a  marked  diminution  in  their  number. 
Should  the  number  drop  below  fifty  per  microscope- 
field,  counting  is  easier.  When  it  is  a  question  of 
closing  a  wound,  half  a  score  fields  should  be  looked 
over  carefully.  When  the  smears  no  longer  yield 
microbes,  or  only  one  to  five  or  six  fields,  then  the 
surgeon  should  be  notified  as  to  the  possibility  of  suture. 

The  bacteriological  condition  of  the  wound  is  ex- 
pressed by  a  fraction  in  which  the  numerator  gives  the 
number  of  microbes  observed,  while  the  denominator 
shows  the  number  of  fields  examined. 

Graphically,  the  bacteriological  state  may  be  repre- 
sented on  a  chart,  where  time  is  shown  in  the  abscissae, 
and  the  number  of  microbes  contained  in  a  microscope- 
field  in  ordinates  (Fig.  51).  As  it  frequently  happens 
that  only  a  single  microbe  is  seen  for  two,  five,  or  ten 
fields,  this  is  expressed  by  J,  1,  or  j\y  microbe  per  field. 

Each  patient  has  a  chart  which  informs  the  surgeon 
concerning  the  condition  of  the  wound  day  by  day. 

4th.  Causes  of  Error. — Certain  mistakes  should  be 
avoided  when  taking  specimens.  In  the  first  place, 
haemostasis  must  be  absolute  at  the  moment  of  taking 
the    specimen.      When    the    secretions    are   diluted    by 


i6o     TREATMENT   OF   INFECTED    WOUNDS 

blood,  microbes  can  no  longer  be  discerned.  It  is  for 
this  reason  that  the  "  smear  "  method  gives  no  indica- 
tion in  the  great  number  of  cases  as  to  the  state  of 
infection  of  fresh  wounds.^ 

So  long  as  haemorrhage  persists,  it  is  useless  to  make 
smears.     Again,  in  examining  wounds  of  longer  standing, 


MOIS}               iJeptembre 

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^*''„_ .,,      ,    Assassfc-J \ L. -J. 

Fin.  51. — Microbial  Chart.  In  the  upright  columns  are  noted  the  number  of 
microbes  found  per  microscope  field,  varying  from  infinity  to  i  and  from 
T  to  t/,-,.  a  twentieth  implies  one  microbe  per  twenty  fields  of  the  micro- 
scope.    The  upper  horizontal  column  marks  the  date. 


it  is  necessary  to  take  the  specimens  at  a  time  when  the 
secretions  are  not  diluted  by  hypochlorite,  and  from 
regions  where  infection  still  persists.  The  smooth 
surface  of  muscles  is  rapidly  sterilised,  so  that  specimens 
taken  in  those  regions  do  not  give  a  true  idea  of  the 
real  state  of  the  wound.     Many  specimens  from  different 

'  Ignorance  of  this  detail  has  caused  certain  surgeons  to  believe  that 
fresh  wounds  are  not  infected. 


PLATE    I, 


■'■     •     *f    ... 


*.    ^ 


Fig. 


Fig.  56. 


Fracture  of  the  femur  in  its  middle  portion  by  a  ball  (Case  522).  Fig.  52. — May  28. 
Rod-like  bodies  in  immense  numbers.  Fig.  53. — May  31.  The  rods  have  almost 
disappeared,  and  have  been  replaced  by  an  immense  number  of  cocci.  Fig.  54. — 
June  3.  About  30  cocci  per  microscope  field.  They  are  usually  in  clusters.  Fig.  55. — 
June  7.  10  to  15  cocci  per  microscope  field.  Fig.  56. — June  13.  About  2  microbes 
per  field.  Fig.  57. — One  coccus  to  10  or  20  fields  of  the  microscope.  The  wound 
is  aseptic.  (The  illustrations  represent  onlv  the  central  portion  of  the  field  of  the 
microscope.)  '  [To  face  pa^'e  160. 


BACTERIOLOGICAL    EXAMINATION      i6r 

regions    of  the   same  wound   must  be    taken,   to  avoid 
error. 

B.  Results  of  the  Examination. — The  examination  of 
the  wound  allows  us  to  estimate,  according  to  the  bacterio- 
logical condition  and  the  anatomical  elements  present  in 
the  secretions,  the  degree  of  sterilisation  of  the  wound- 
By  counting  every  two  or  three  days  the  microbes  con- 
tained in  secretions  taken  from  different  parts  of  the 
wound,  and  by  studying  the  evolution  of  the  leucocytes, 
the  progress  of  sterilisation  can  be  followed. 

1st.  Modifications  of  the  Bacteriological  Condition  of 
the  Wound,  (a)  Fresh  Wounds. — Smears  from  wounds 
less  than  twelve  hours  old  rarely  show  microbes.  They 
are  only  found  in  the  immediate  neighbourhood  of 
shreds  of  clothing  on  the  surface  of  crushed  muscle,  and 
are  usually  rod-like  bodies.  They  are  very  few  in 
number,  and  the  microscope  field  has  to  be  moved 
several  times  to  discover  one.  Occasionally  when  the 
wounds  are  six  or  eight  hours  old,  the  smears  yield 
microbes  plentifully.  If  no  microbes  are  seen  in  the 
secretions  of  a  fresh  wound,  it  will  not  do  to  conclude 
that  the  wound  is  sterile,  but  simply  that  the  microbes 
are  still  few  in  number  and  so  diluted  by  blood  that  they 
cannot  be  seen.  Experiment  has  demonstrated  that,  in 
cases  where  the  smears  are  negative,  cultures  made  from 
fragments  of  shell  or  clothing,  debris  of  muscle  or  con- 
nective tissue  taken  from  the  immediate  vicinity  of 
foreign  bodies,  give  positive  results.  Almost  always, 
anaerobic  cultures  made  under  these  conditions  produce 
gas.  It  might  be  said  that  every  shred  of  cloth  can 
determine  a  gas  infection. 

At  the  end  of  twenty- four  or  thirty- six    hours,  the 

II 


i62     TREATMENT   OF   INFECTED   WOUNDS 


secretions  of  the  wound  often  yield  microbes  (Fig. 
52).  The  topographical  variations  of  infection  are  less 
marked,  and  these  differences  diminish  as  the  secretions 
become  more  abundant.  Twenty-four  or  forty-eight 
hours  after  the  commencement  of  instillation  of  hypo- 
chlorite, the  topography  of  infection  and  its  volume  are 


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Fig,  58. — Curve  representing  the 
sterilisation  of  the  wound  in  Case 
522.  It  shows  that  the  microbes 
which  were  in  great  number  on 
May  31,  diminished  and  practically 
disappeared  by  June  17, 


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Fig.  59. — Right  kiiee.  Woitvd  ex- 
terfial.  Typical  curve  of  sterilisa- 
tion of  a  wound  of  the  soft  parts. 
The  wound,  which  contained  40 
microbes  per  microscope  field  at 
the  time  of  the  first  examination, 
was  surgically  sterile  two  days  later. 


modified.  The  surface  of  normal  muscle  only  shows 
half  a  score  microbes  per  field,  whilst  they  are  beyond 
counting  on  the  surface  of  fractured  bone  and  especially 
in  the  debris  of  necrosed  muscular  or  cellular  tissue. 
After  two,  four,  or  six  days,  the  greater  part  of  the 
surface  of  the  wound  is  sterile,  but  microbes  remain  on 
irregular  bony  surfaces,  and  in  deep  culs-de-sac  which 


BACTERIOLOGICAL   EXAMINATION      163 


have  not  been  reached  by  the  liquid  (Figs.  54  and  55). 
Fragments  of  necrosed  tissue  still  contain  the  same 
quantity  of  microbes.  The  moment  the  solution  of  these 
tissues  by  the  hypochlorite  is  achieved,  there  is  an  abrupt 
drop  in  the  bacteriological  curve,  and  sterilisation  will 
then  be  complete  in  one  or  two  days. 

In  wounds  of  the  soft  parts,  microbes  disappear  from 


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Fig.  6o. — Compound  fract  it  re  of  tibia.  Sterilisation  curve  of  a  highly  com- 
minuted fracture  of  the  tibia.  The  first  smear  was  negative  because 
the  wound  was  fresh.  The  third  was  equally  so  because  of  the  presence 
of  blood.    Sterilisation  the  ninth  day. 

the  secretion,  generally,  from  the  third  to  the  tenth  or 
twelfth  day  (Fig.  59).  In  very  irregular  wounds,  and  in 
those  associated  with  injuries  to  bone,  microbes  persist 
much  longer  (Figs.  52-58  and  60).  The  microbes  dis- 
appear at  first  from  the  muscles,  and  from  normal  cellular 
tissue,  afterwards  from  the  bony  surfaces.  The  last 
places  in  which  they  are  to  be  found  are  on  fragments 
of  necrosed  tissue,  and  more  particularly  on  tendons  and 


i64     TREATMENT   OF    INFECTED    WOUNDS 

fasciae.  As  a  general  rule,  after  eight,  ten,  or  twelve 
days,  the  entire  surface  of  the  wound  is  aseptic,  except 
where  there  are  still  necrosed  aponeuroses  or  narrow  and 
deep  tracks.  In  these  cases,  instillations  of  hypochlorite 
have  not  the  power  to  alter  the  topography  of  infection. 

The  aseptic  cicatrisation  of  a  wound  presenting 
a  constant  source  of  reinfection,  such  as  the  opening  of 
a  sinus  unceasingly  discharging  microbes,  can  thus  be 
followed.  For  example,  on  the  surface  of  a  large  wound 
of  the  abdominal  wall  there  opened  a  narrow  sinus  leading 
down  to  the  fractured  ilium. 

The  surface  of  the  wound  was  aseptic,  whilst  the 
secretions  collected  at  the  mouth  of  the  sinus  still  con- 
tained a  great  number  of  microbes.  The  wound  there- 
fore showed  two  quite  distinct  zones,  one  aseptic  and 
the  other  infected.  The  instillation  was  continued  for 
several  weeks.  From  time  to  time  reinfection  came 
from  the  sinus,  but  it  only  lasted  a,  few  hours,  because 
the  septic  part  of  the  surface  of  the  granulations  became 
almost  immediately  sterilised  by  the  solution.  The  in- 
fection was  thus  kept  within  narrow  bounds  at  the  mouth 
of  the  sinus  and  the  whole  of  the  vast  abdominal  wound 
became  cicatrised  like  an  aseptic  wound. 

An  analogous  limitation  of  the  infection  to  a  very 
small  part  of  the  wound  has  been  observed  in  many 
cases.  But  if,  at  this  period  of  sterilisation,  the  instilla- 
tions are  stopped,  total  reinfection  of  the  wound  takes 
place  in  a  day  or  two.  When  the  cases  whose  wounds 
are  almost  completely  sterilised  are  transferred  to  a 
hospital  where  a  different  method  is  employed,  suppura- 
tion appears  at  the  end  of  from  two  to  three  days.  It  is 
therefore  necessary  to  continue  the  sterilisation  until  it] 


BACTERIOLOGICAL   EXAMINATION      165 


is  complete.  If,  on  the  surface  of  a  wound  almost  com- 
pletely aseptic,  there  still  persists  the  mouth  of  a  sinus 
leading,  either  to  a  bony  lesion,  or  to  a  fragment  of 
necrosed  tissue  containing-  microbes,  or  to  some  infected 
foreign  body,  reinfection  always  follows  without  fail 
directly  the  instillation  is  stopped.  On  the  other  hand, 
careful  instillation  of  the  solution  into  a  wound  allows 
it  to  become  cicatrised  as  rapidly  as  if  it  were  completely 
aseptic,  even  in  cases  where  there  exists  a  region  still 
containing  microbes. 

It  is  equally  important  to  examine  the  surface  of 
the  skin  surrounding  the  wound.  Completely  aseptic 
wounds  may  become  rein- 
fected after  the  instillation  is 
stopped,  because  on  the  sur- 
face of  the  epithelial  border 
and  the  adjoining  skin  are 
many  microbes  (Fig.  61). 
These  reinfections  of  cu- 
taneous origin  may  greatly 
retard  the  progress  of  cica- 
trisation (Figs.  62  and  63). 
An  examination  of  the  epi- 
thelial scales  which  cover  the 
skin  near  the  wound,  shows 
that  they  are  loaded  with 
masses  of  microbes.  That  is 
the  reason  it  is  essential  to 
wash  with  neutral  oleate  of 
soda,  not  only  the  surface  of  the  wound,  but  the  whole 
of  the  region  adjoining. 

In  short,  examination  of  the  smears  of  the  secretions 


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Fig.  61. — Burn.  Curve  showing  a 

reinfection    of  cutaneous    origin 

upon  a  surface  wound  previously 
aseptic. 


i66     TREATMENT   OF   INFECTED   WOUNDS 


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Fig.  63. — Cicatrisation  curve  of  the  preceding  wound.  It  is  seen  that  the 
cicatrisation  has  slowed  down  considerably  from  Jan.  14  to  Feb.  28,  and 
that  the  slowing  down  coincides  with  the  period  of  reinfection  indicated 
by  the  preceding  microbial  curve  (Fig.  62). 


bactp:riological  examination    167 

collected  from  different  parts  of  the  wound,  and  of  the 
results  of  the  scrapings  of  the  skin  and  epithelial  margin, 
shows,  from  the  time  of  the  instillation  of  the  antiseptic 
treatment,  profound  modifications  in  the  topography 
of  the  infection.  Microbes  disappear  completely  from 
the  greater  portion  of  the  wound,  but  still  persist  in 
the  necrosed  tissue,  upon  irregular  bony  surfaces,  and 
upon  the  skin.  As  soon  as  the  necrosed  tissue  is 
dissolved  by  the  hypochlorite,  the  microbes  which  were 
in  this  nidus  disappear  also.  Those  on  the  skin  and 
osseous  surfaces  persist  longer.  It  is  necessary,  there- 
fore, before  looking  upon  a  wound  as  aseptic,  to  examine 
those  regions  which  are  the  last  strongholds  of  infection, 
and  not  to  stop  the  treatment  before  being  quite  sure 
that  microbes  have  been  eliminated  from  the  whole 
extent  of  the  wound. 

Variations  in  quantity  alone  of  microbes  are  to  be 
considered,  because  the  hypochlorite  destroys  microbes 
without  distinction  of  species.  Nevertheless,  in  the 
course  of  sterilisation,  modifications  in  the  aspect  of  the 
microbial  flora  may  be  seen.  During  the  first  two  or 
three  days,  the  smears  contain  rod-like  bodies,  which 
are  often  bacilli  of  Welch,  and  cocci  (Fig.  52).  Next, 
the  cocci  increase  in  number,  while  the  rods  completely 
disappear  (Fig.  53).  Now  on  the  microscope  field  are 
to  be  seen  nothing  but  isolated  cocci,  diplococci,  clusters 
of  staphylococci  (Fig.  54),  and  chains  of  streptococci. 
Under  the  influence  of  the  antiseptic  the  number  of 
microbes  diminishes  (Figs.  55  and  56),  and  finally  a  few 
diplococci  alone  persist  for  a  few  days,  then  disappear 
completely. 

{b)   Suppurating    Wounds. — In  wounds  which   have 


i68     TREATMENT    OF    INFECTED   WOUNDS 

reached  the  suppuration  stage  before  the  treatment  was 
begun,  the  topography  of  infection  is  nearly  uniform. 
Specimens  taken  from  different  regions  indicate  every- 
where the  presence  of  an  almost  equal  number  of 
microbes.  Every  morphological  variety  is  represented. 
The  microbes  are  sometimes  isolated,  sometimes  in 
clusters,  or  again  within  the  leucocytes.  Sometimes 
they  are  so  numerous  that  they  form,  under  the  micro- 
scope, an  almost  continuous  layer.  At  the  same  time, 
the  quantity  of  microbes  contained  in  pus  is  extremely 
variable,  according  to  the  treatment  which  the  injury 
has  received.  We  have  examined  secretions  from  the 
wounds  of  casualties  arriving  in  the  Paris  hospitals  after 
having  been  treated  in  the  field  hospitals  at  the  front 
by  the  usual  methods,  such  as  ether  or  saline  solution. 
All  these  wounds  were  suppurating,  and  the  numbers 
of  microbes  contained  in  the  secretions  were  sometimes 
so  great,  that  any  attempt  at  counting  was  impossible. 
We  have  also  examined  wounds  in  a  fair  way  to  suppu- 
rate coming  from  hospitals  {ambulances^  Fr.)  where 
sterilisation  by  means  of  Dakin's  solution  had  been 
practised.  As  the  technique  had  been  imperfectly 
carried  out,  these  wounds  contained  pus,  but  in  this  pus 
only  some  fifteen  to  twenty  microbes  were  found,  and 
sometimes  only  three  or  four  per  microscope  field. 
Therefore  there  are  considerable  differences  in  the  degree 
of  infection,  and  no  clinical  sign  enables  one  to  dis- 
tinguish a  pus  containing  a  large  quantity  of  microbes 
from  another  sample  of  pus  containing  only  a  small 
number. 

When  a  suppurating  wound   is  being  sterilised,  the 
bacteriological  curve  declines  almost  immediately,  and  one 


BACTERIOLOGICAL   EXAMINATION      169 


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towards  the  15th  day. 


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Fig,  65. — Very  large,  deep,  and  irregular  wound  in  the  posterior  part  of  the 
thigh  and  the  left  obturator  region  ;  arrival  at  hospital  in  full  tide  of 
infection.  Almost  immediately  suppuration  disappeared  completely. 
Diminution  in  the  number  of  microljes  became  manifest  17  days  after  the 
conmiencement  of  treatment,  and  the  immense  wound  was  quite  sterile 
and  able  to  be  closed  26  days  after  the  entrance  of  the  case  into  hospital. 


i;o     TREATMENT    OF   INFECTED   WOUNDS 


of  two  phenomena  may  appear.    In  the  first  case  the  curve 

goes  lower  and  lower.     At  the  end   of  a  few  days  the 

microbes   disappear  entirely,  and   sterilisation  comes  to 

pass  as  though  a  fresh  wound  were  in  question  (Figs.  64, 

65,  and  66).     The  same  evolution  may  be  seen  in  surface 

wounds  and  in  certain  deep  wounds 

of  the  soft  parts.     But  sometimes, 

after  one  or  several  days  of  almost 

complete   sterility,  the  pus  yields 

anew  a  large  quantity  of  microbes 

(Fig.   64),  which   are   more   often 

than  not  in  clusters.     These  sharp 

ascents  of  the  bacteriological  curve 

are  due  to  the  circumstance  that 

little  pockets  of  pus,  isolated  from 

the  principal  cavity  of  the  wound, 

have    become    opened    and    have 

scattered  their  contents  over  the 

newly  sterilised  walls.     These  re- 

^'on^L^^l\  ^peci''^-''^^-,  infections  are  especially  observed 
wound  on  external  aspect  \^-^  y^j-y  irregular  wounds,  and  in 

.     Wounds  of  the  soft  ^  ^  ' 

parts,     suppurating     and  compound   fractures.     Under   the 

highly  infected.     The  num-    .     _  -...,,.  .         , 

bcr  of  microbes  was  im-  influence  oi  instillation,  mici'obes 
oSed^^dSr^St  "^^y  disappear  again  fVom  the 
days  after  the  begninmg  of  p^s,    either    temporarily   or    per- 

treatment.  r      '  tr  j  f 

manently. 
In  the  second  case,  the  bacteriological  curve  drops 
under  the  influence  of  the  antiseptic  liquid,  then,  when 
it  has  reached  a  certain  level,  becomes  horizontal. 
However  generous  may  be  the  instillations,  the  microbes 
no  longer  diminish  in  numbers  (Fig.  67).  Occasion- 
ally in  the  same  patient  some  wounds  become  completely 


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BACTERIOLOGICAL   EXAMINATION      171 

sterile,  whilst  others  still  contain  more  than  fifty 
microbes  per  microscope  field.  The  persistence  of 
microbes  in  the  secretions  of  a  wound  in  spite  of  the 
treatment,  indicates  the  presence,  in  the  deeper  parts 
of  the  wound,  of  foreign  matter,  such  as  shreds  of 
clothing,  fragments  of  projectile,  a  splinter  of  bone,  a 
morsel  of  necrosed  tissue  ;  or  perhaps  a  focus  of  osteitis 


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Fig.  67. — Deeply  infected  compound  fracture  of  the  tibia  becoming  sterilised 
in  a  partial  manner.  The  reinfection  which  occurred  from  the  23rd  to 
the  29th  decided  us  to  remove  a  fragment  of  sphacelated  tendon  which 
had  been  acting  as  a  foreign  body.    Sterilisation  was  obtained  in  two  days. 


(Fig.  6'j).  If  therefore,  after  having  made  sure  that  the 
instillation  of  fluid  has  been  sufficient  and  continued, 
and  that  the  conducting  tubes  are  correctly  placed,  it  is 
noticed  that  the  number  of  microbes  does  not  lessen,  an 
exploration  of  the  wound  should  be  made,  in  order  to 
remove  the  foreign  bodies,  or  scrape  the  bony  surfaces 
which    are    keeping    up   the    infection ;   and    then    the 


172     TREATMENT   OF   INFECTED   WOUNDS 

instillations  of  Dakin's  solution  should  be  continued. 
Following  upon  this  interference,  the  number  of  microbes 
increases  greatly.  Afterwards  the  curve  drops,  the 
microbes  diminish  in  number,  and  may  completely  dis- 
appear (Fig.  6*]).  In  short,  every  time  that  a  wound 
does  not  respond  to  treatment  by  a  progressive  diminu- 
tion in  the  number  of  microbes,  it  is  necessary,  after 
having  ascertained  that  the  technique  of  the  treatment 
has  been  duly  observed,  to  search  for  foreign  bodies  or 
bony  lesions.  If  the  source  of  the  reinfection  cannot 
be  traced,  complete  sterilisation  becomes  impossible. 

To  resume,  in  the  greater  number  of  wounds,  new  or 
old,  the  number  of  microbes  diminishes  rapidly  up  to 
the  time  when  each  microscope  field  contains  from  one 
to  ten.  If  at  this  stage,  the  instillation  is  practised  in 
an  abundant  degree,  the  secretions  will  soon  show  only 
one  microbe  to  two,  five,  or  even  ten  fields  of  the  micro- 
scope. When  the  curve  does  not  go  down  in  this  way, 
the  cause  must  be  looked  for  and  found. 

2nd.  Characters  of  the  Leucocytes. — From  the  twelfth 
hour,  the  polynuclear  leucocytes  are  seen  in  more  or  less 
abundance  in  the  wound.  During  the  early  days  the 
secretions  are  composed  especially  of  polynuclear  cells 
more  or  less  altered,  of  a  small  number  of  lymphocytes, 
and  of  mononuclear  cells.  The  microbes  are  free,  or 
within  the  phagocytes.  So  long  as  they  persist  in 
great  numbers  in  the  secretions,  the  relative  proportion 
of  polynuclear  and  mononuclear  cells  changes  very 
slightly. 

In  wounds  treated  by  hypochlorite  or  chloramines, 
the  free  anatomical  elements  are  altered  to  the  same 
degree  as  the  microbes.     Nevertheless,  many  polynuclear 


BACTERIOLOGICAL   EXAMINATION      173 

cells  enclose  microbes  which  they  have  devoured  before 
being  themselves  killed  by  the  hypochlorite.  It  is 
therefore  probable  that  the  normal  phenomena  of 
defence  occur  as  effectually  in  wounds  treated  by 
hypochlorite  as  in  those  treated  by  saline  solution. 
In  reality,  the  hypochlorite  does  not  penetrate  into  the 
depths  of  the  tissues.  In  consequence,  in  the  regions 
not  touched  by  the  antiseptic,  phagocytosis  goes  on 
as  usual.  In  all  the  regions  affected  by  the  hypo- 
chlorite, the  leucocytes  are  destroyed,  but  inasmuch  as 
the  microbes  suffer  the  same  fate,  no  real  inconvenience 
results.  Hypochlorite,  having  a  much  more  energetic 
action  than  the  fluids  of  the  organism  or  the  polynuclear 
cells,  replaces  these  agents  of  defence  in  their  functions. 
It  is  ignorance  of  these  elementary  principles  which 
has  inspired  certain  French  writers  with  a  futile  respect 
for  what  they  call  cytophylactic  substances. 

From  the  moment  when  microbes  become  rare  in 
the  secretions,  the  anatomical  elements  change  their 
nature.  Mononuclear  cells  increase  in  number.  At  the 
same  time  we  note  the  appearance  of  large  cells  with  a 
single  nucleus  and  fine  filaments.  It  is  the  indication 
that  the  wound  is  almost  aseptic.  At  the  same  time 
these  modifications  of  the  anatomical  elements  are  only 
of  secondary  importance  in  the  study  of  the  progress  of 
sterilisation.  Although  the  disappearance  of  the  poly- 
nuclear cells  and  the  appearance  of  large  mononuclear 
cells  indicates  almost  always  a  marked  degree  of  sterility, 
the  persistence  of  a  large  number  of  polynuclear  cells  in 
no  way  implies  that  the  wound  is  not  becoming  sterilised. 
In  fact  we  frequently  see  secretions  composed  of 
extremely    numerous   altered,    polynuclear    cells    which, 


174     TREATMENT   OF    INFECTED   WOUNDS 

liowever,  contain  no  microbes.  Therefore,  to  judge  the 
condition  of  a  wound,  it  is  necessary,  above  all,  to  base 
the  opinion  upon  the  presence  or  absence  of  micro- 
organisms. 

C.  Value  of  the  Method. — The  method  we  have  just 
described  permits  a  large  number  of  wounds  to  be 
examined  in  a  short  time.  But  it  is  far  from  being 
exact.  So  we  must  enquire  if  the  simple  counting  of 
microbes  on  a  smear  gives  sufficient  information  of  the 
bacteriological  condition  of  the  wound. 

The  technique  carries  with  it  obvious  possible  sources 
of  error.  In  the  first  place,  the  smears  are  of  varying 
thickness,  according  to  the  nature  of  the  secretions  and 
the  manner  in  which  they  are  spread  out  on  the  surface 
of  the  slide.  Next,  the  counting  of  microbes  contained 
in  a  microscope  field  is  of  necessity  far  from  being  exact. 
If  it  were  a  question  of  finding  out  precisely  the  quantity 
of  microbes  contained  in  any  given  volume  of  secretion, 
the  method  would  be  absolutely  inadequate.  But  we 
are  not  here  engaged  in  scientific  research.  We  desire 
nothing  more  than  a  clinical  indication.  In  a  word,  the 
surgeon  seeks  to  learn  if  the  quantity  of  microbes  in  a 
wound  under  treatment  is  lessening,  and  when  these 
disappear  completely. 

To  appreciate  the  diminution  in  the  number  of 
microbes  contained  in  the  secretions  of  a  wound,  it  is 
of  little  moment  that  mistakes  of  considerable  magnitude 
may  be  made  in  the  counting.  Errors  of  ten  per  cent, 
or  even  thirty  per  cent,  are  of  no  great  importance.  If 
one  day  there  is  found  in  the  pus  an  uninterrupted  mass 
of  microbes,  and  the  next  day  only  a  hundred  per 
microscope  field  can  be  counted,  it  is  evident  that  their 


BACTERIOLOGICAL   EXAMINATION      175 

number  has  lessened.  It  really  matters  little  that  there 
may  have  been  two  hundred  or  even  fifty,  instead  of 
a  hundred  (Figs.  6S  and  69).  And  in  the  same  way, 
if  on  the  following  day  one  counts  ten  per  micro- 
scope field,  it  is  of  minor  im- 
portance that  an  error  of  twenty- 
five  per  cent,  or  of  fifty  per  cent, 
may  have  been  made,  because  it 
is  certain  that  the  volume  of  in- 
fection has  diminished.  To  sum 
up,  important  mistakes  in  count- 
ing do  not  prevent  us  from  mark- 
ing on  the  bacteriological  charts 
the  progressive  lessening  of  in- 
fection, because  the  variations  in 
the  quantity  of  microbes  under 
the  influence  of  treatment  are 
very  considerable  (Figs.  68  and 
70).       Besides,     experience     has 

shown  that  if  the  examinations  Fig.  68.-Curve  represent- 
ing the  sterilisation  of  the 
wound  in  Case  318.  Jan. 
10,    the    wound    contained 


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a  large  number  of  microbes. 
On  Jan.  16  only  one  per 
microscope  field  could  be 
found,  and  by  Jan.  20 
microbes  had  completely 
disappeared  from  the 
smears. 


are  made  by  the  same  person 
under  identical  conditions,  the 
results  are  quite  consistent,  and 
that  the  evolution  of  the  wound 
under  treatment  can  be  fol- 
lowed with  quite  sufficient  ac- 
curacy. 

The  date  of  the  disappearance  of  microbes  is  indicated 
with  ample  precision  by  the  preceding  methods.  From 
the  time  when  the  secretions  contain  only  half  a  score 
microbes  per  microscope  field,  counting  becomes  easier 
(Figs.  68  and  yd).     It   can    be    done    with    still   more 


176     TREATMENT   OE    INFECTED    WOUNDS 

precision  when  only  one  or  two  microbes  per  field  are 
to  be  found  (Fig.  71).  If  the  secretions  collected  from 
the  different  regions  of  a  wound  do  not  contain  more 
than  one  microbe  to  five  or  six  fields,  the  wound  may  be 
looked  upon  as  being  surgically  sterile. 

At  the  same  time,  clinical  signs  must  not  be  alto- 
gether lost  sight  of  In  reality,  a  wound  vv^hose  secre- 
tions no  longer  yield  microbes  in  the  smears,  may  still 
be  infected.  When  a  wound  has  suppurated  during  a 
long  period  before  being  submitted  to  chemical  sterilisa- 
tion, microbes  are  already  encapsuled  in  the  scar-tissue 
[englobe,  Fr.).  The  surface  of  the  wound  may  be  sterile, 
while  microbes  remain  latent  in  the  deeper  parts.  In 
this  case,  the  clinical  history  indicates  to  the  surgeon 
that  the  deeper  portions  of  a  wound,  sterile  in  appear- 
ance, may  be  infected  ;  and  that  in  closing  such  a  wound, 
it  is  not  prudent  to  make  use  of  deep  interstitial  sutures, 
which  of  necessity  would  set  up  reinfection.  In  wounds 
which  have  never  suppurated,  and  of  which  the  secre- 
tions are  sterile,  diverticula  may  have  succeeded  in 
escaping  the  antiseptic  liquid,  and  may  serve  as  a  refuge 
for  microbes.  That  is  the  reason  why  the  temperature 
should  always  be  taken.  If  a  man  whose  wound  is  to 
all  appearance  sterile  has  an  evening  temperature  of 
37-8^  or  37-9^  C.  (100"  or  100*2°  Fahr.),  it  is  probable  that 
a  little  pocket  is  cut  off  from  the  main  cavity  and  which 
is  not  completely  disinfected. 

The  disappearance  of  microbes  from  the  smears  by 
no  means  implies  that  the  wound  is  really  aseptic.  It 
simply  indicates  that  the  degree  of  sterility  compatible 
with  closure  of  the  wound  has  been  attained.  We  are 
seeking,    in    fact,    surgical    asepsis,    not    bacteriological 


PLATE    II 


Fig.  69.        -*«*4®te 


Fig. 


Very  large  wound  of  the  posterior  region  of  the  leg  (Case  318).  Fig.  68.— 
Tan.  10  .  More  than  100  microbes  per  microscope  field.  Fig.  69. — Jan.  12. 
About  10  microbes  per  field.  Fig.  70.— Scarcely  one  per  field.  (The 
illustrations  represent  only  the  central  part  of  the  field  of  the  microscope.) 

\To  face  page  176. 


BACTERIOLOGICAL    EXAMINy\TION     177 

asepsis.^  In  the  majority  of  cases,  the  secretions  of 
wounds  whose  smears  no  longer  yield  a  microbe  still 
give  positive  cultures.  Certain  writers — for  example, 
Policard^ — even  believe  that  chemical  sterilisation  never 
achieves  absolute  asepsis  of  a  wound.  However,  by 
the  aid  of  a  precise  technique,  the  surface  of  a  wound 
can  be  rendered  so  aseptic  that  cultures  from  its 
secretions  remain  sterile.  In  several  cases  we  have  been 
able  to  obtain  this  result.^  But  this  degree  of  asepsis 
is  of  no  practical  interest. 

Finally,  bacteriological  examination  in  the  simplified 
form  we  have  just  described,  should  be  looked  upon  as 
an  indispensable  part  of  the  method  of  wound  sterilisa- 
tion, because  it  allows  the  progress  of  treatment  to  be 
followed  step  by  step,  and  indicates  that  it  should  be 
modified  if  the  number  of  microbes  does  not  steadily 
lessen.  Alone,  it  can  point  out  the  moment  when  a 
wound  may  be  closed.  Indeed,  a  wound  should  never 
be  sutured  if  one  is  ignorant  of  what  it  contains. 
Despite  its  lack  of  scientific  precision,  the  study  of 
smears  gives  to  the  surgeon  clinical  information  which 
is  indispensable  for  the  direction  of  treatment. 

'  Pozzi,  Bulletin  de  V Ac ademie  de  Medecine^  meeting  Jan.  ii,  1916. 

-  Policard,  loc.  cit. 

^  M.  Vincent  found  that  in  six  cases  out  of  nineteen  injuries  treated  by 
the  usual  methods  at  Compiegne  by  MM.  Guillot  and  Woimant,  bacterio- 
logical asepsis  had  been  attained. 


13 


CHAPTER   VI 

THE    CLOSURE    OF   WOUNDS 

The  corollary  to  the  sterilisation  of  a  wound  is  its 
closure.  But  a  wound  should  never  be  closed  without 
knowing  what  it  contains.  Suture  of  a  wound  enclosing 
microbes  may  be  followed  by  downright  disaster.  It  is 
therefore  only  after  having  carefully  looked  into  the 
bacteriological  condition  of  a  wound  that  one  may  bring 
its  edges  together  by  strapping  or  suture. 

I.  The  Time  for  Closure 

Closure  of  a  wound  is  practised  as  soon  as  we  know 
that  it  no  longer  contains  microbes.  Therefore  primary 
closing  should  be  rejected.  Even  after  precise  mechani- 
cal cleaning  of  the  wound,  and  resection  of  every  portion 
which  has  been  affected  by  the  projectile,  still  it  is 
impossible  to  make  sure  that  microbes  have  not  been 
left  on  the  surface  of  the  tissues.  So  far  as  that  goes, 
the  negative  aspect  of  smears  made  with  the  liquids  or 
tissue  taken  from  a  fresh  wound  has  no  value  whatever. 
A  highly  infected  wound,  at  this  stage,  may  not  show  a 
bacterium  upon  the  slide.  Only  cultures  made  by  means 
of  tissues  carefully  collected  from  numerous  points  in 
the    wound    can    give    an    idea    of    its    bacteriological 

178 


THE  CLOSURE   OF  WOUNDS  179 

condition.  But  to  have  the  report  of  cultures  it  is 
necessary  to  wait  twenty-four  or  forty-eight  hours. 
Consequently  it  becomes  impossible  to  practise  primary 
union  of  a  wound.  At  the  beginning  of  the  war  primary 
union  was  employed,  and  given  up  because  of  the 
disasters  it  provoked.  Nearly  all  the  cases  of  septi- 
caemia we  have  seen  here  followed  unseasonable  suture 
by  people  who  were  still  ignorant  of  the  danger.  In 
a  certain  number  of  cases  one  may  be  favoured  by 
fortune  and  close  wounds  which  are  but  slightly  infected, 
and  which  unite  by  first  intention.  But  experience  has 
shown,  over  and  over  again,  that  gas-producing  septi- 
caemia and  streptococcal  septicaemia  have  caused  the 
death  of  the  patient  who  has  been  the  subject  of  these 
experiments.  A  siirgeon  has  not  the  right  to  cause  a 
single  ivoiinded  man  to  risk  useless  dangers.  Therefore 
primary  closure  of  wounds  must  be  absolutely  rejected 
so  long  as  we  do  not  possess  a  means  of  knowing 
whether  they  are  sterile  or  not. 

A.  Secondary  closure,  on  the  contrary,  can  be  done 
under  such  conditions  that  it  presents  no  danger.  The 
examination  of  smears  of  the  secretions  of  a  wound 
aged  twenty-four  hours  or  more  enables  the  volume  of 
infection  to  be  estimated.  When  the  number  of  microbes 
has  diminished  progressively,  when  it  has  become  zero, 
and  this  condition  is  maintained  for  two  or  three  days, 
then  we  may  be  sure  that  an  adequate  degree  of 
asepsis  has  been  reached,  and  that  the  wound  may  be 
sutured.  At  the  same  time,  we  must  not  lose  sight 
of  other  clinical  signs,  especially  the  patient's  tempera- 
ture and  the  condition  of  the  limb.  When  the  indica- 
tions   furnished    by   both    clinical    aspect    and    smears 


i8o    TREATMENT   OF    INFECTED   WOUNDS 

coincide,  then  one  may  suture  the  wound  with  a  feeling 
of  entire  security. 

B.  A  wound  of  the  soft  parts  whose  sterilisation  has 
been  begun  a  few  hours  after  infliction,  and  which  has 
never  suppurated,  may  be  closed  as  soon  as  two  consecu- 
tive examinations,  made  after  an  interval  of  one  or  two 
days,  have  shown  that  the  smears  do  not  contain  more 
than  one  microbe  to  four  or  five  microscope  fields.  If  the 
wound  be  deep,  and  especially  if  it  be  associated  with 
fracture,  above  all,  a  compound  fracture  of  the  thigh,  it 
is  preferable  to  repeat  the  examinations  and  to  wait, 
before  closing  the  wound,  until  it  has  been  surgically 
sterile  for  four  or  five  days. 

C.  The  time  for  the  closure  of  wounds,  the  sterilisa- 
tion of  which  has  been  begun  after  a  period  of  suppura- 
tion more  or  less  long,  is  determined  more  carefully. 
And  so  far  as  that  goes,  experience  has  taught  us  that 
the  secretions  of  a  suppurating  wound,  above  all  when  it 
is  deep  and  that  of  a  compound  fracture,  may  become 
for  a  little  while  sterile,  without  the  wound  being  really 
permanently  so.  One  day  the  pus  is  to  all  appearances 
aseptic,  and  the  next  day  are  found  indubitable  heaps 
of  microbes  accumulated  on  certain  points  of  the  smear. 
In  these  wounds,  which  have  suppurated  for  so  long 
before  the  commencement  of  antiseptic  treatment,  one 
should  find  the  secretions  sterile  for  a  week  at  least 
before  deciding  to  suture. 

D.  Generally,  the  average  time  for  wound  closure 
varies  between  the  eighth  and  twelfth  day.  Some 
wounds  may  be  united  towards  the  fifth  or  sixth  day, 
others  after  the  twelfth.  Certain  compound  fractures 
should  not  be  closed   before  the  twentieth   or  thirtieth 


THF:   closure    of   wounds  iSi 

day  of  treatment.  It  is  well  to  practise  the  closing  of 
wounds  at  as  early  a  period  as  possible.  As  a  matter 
of  fact,  wounds  united  before  the  eighth  day  contain 
no  cicatricial  tissue,  and  healing  comes  to  pass  without  a 
legacy  of  functional  troubles.  The  closure  of  wounds 
at  an  early  period  also  results  in  considerable  saving, 
both  in  the  cost  of  treatment  and  in  the  work  of  the 
staff  of  the  hospital.  In  a  word,  as  soon  as  a  wound 
becomes  sterile,  it  should  be  closed. 


II.  Technique  of  Wound-closing 

Wounds  are  closed  by  strapping,  by  elastic  bands,  or 
sutures. 

A.  Wound-closing  by  Means  of  Strapping. — Co-aptation 
of  the  margins  of  the  wound  by  means  of  bands  of 
adhesive  plaster  may  be  carried  out  so  long  as  spon- 
taneous cicatrisation  has  not  commenced  and  the  skin 
moves  easily  over  the  deeper  parts.  It  causes  no  pain 
to  the  patient  and  demands  neither  local  nor  general 
anesthesia.  Strapping  of  American  make  and  good 
quality  is  used,  four  or  five  centimetres  wide,  twenty  to 
twenty-five  centimetres  long.  The  strips  must  be  long 
enough  to  get  a  firm  grip  on  the  skin.  As  it  is  not 
sterile,  we  must  carefully  avoid  bringing  the  surface  of 
the  strapping  into  actual  contact  with  the  raw  surface 
of  a  wound,  and  the  line  of  union  is  protected  by  a  slip 
of  paper,  or  of  celluloid,  sterilised. 

The  skin  adjoining  the  wound  is  shaved,  thoroughly 
dried,  then  the  lips  of  the  wound  are  brought  together 
and  maintained  exactly  in  correct  position  by  several 
bands    of    strapping    applied     perpendicularly    to    the 


i82     TREATMENT   OF    INFECTED   WOUNDS 

direction  of  the  wound  (Fig.  72).  At  the  end  of  a 
week  the  strapping  is  removed,  and  the  wound  found 
to  be  united. 


Fig.  72. — Bringing  together  the  lips  of  a  wound  by  means  of  strips  of 
adhesive  plaster. 

B.  Wound- closings  by  Elastic  Traction.  —  When  ex- 
tensive loss  of  substance  exists  and  the  lips  of  the  wound 
cannot    be   brought   into   apposition,  recourse  is  had  to 


Fig.  73. — Bringing  together  the  lips  of  a  wound  by  means  of  elastic  traction. 

elastic  traction.     This  method  is  also  used  for  covering 
stumps. 

The  bringing  together  of  the  edges  of  a  wound  by- 
elastic  traction  is  carried  out  in  the  following  manner. 


THE    CLOSURE    OF   WOUNDS  183 

Strips  of  adhesive  plaster  seven  or  eight  centimetres 
wide  (about  three  inches),  and  exceeding  in  length  by 
ten  centimetres  (four  inches)  the  length  of  the  wound, 
are  provided  on  one  edge  with  boot-lace  hooks,  by 
means  of  the  punch  in  use  by  shoemakers.  On  either 
side  of  the  wound  and  parallel  to  it,  a  piece  of  strapping 
bearing  the  boot-lace  hooks  is  made  to  adhere  firmly  to 
the  skin  (Fig.  y^).  The  hooks  of  the  two  strips  are 
brought  towards  each  other  by  means  of  a  lacing  of 
strong  rubber,  the  tension  of  which  is  regulated  to  a 
suitable  degree. 

The  margins  of  the  wound  are  brought  together  pro- 
gressively under  the  influence  of  the  elasticity  of  the 
rubber.  When  there  has  been  no  loss  of  cutaneous  sub- 
stance, or  when  the  loss  is  but  slight,  the  raw  surface  may 
be  covered  in  forty-eight  hours.  When  the  loss  of  sub- 
stance is  more  considerable,  still  this  procedure  allows 
of  the  area  of  the  wound  being  diminished  to  a  very 
large  extent. 

A  similar  method  is  used  to  unite  the  edges  of  flaps 
on  stumps.  It  is  admitted  that,  amputations  being 
nearly  always  practised  on  an  infected  limb,  the  stump 
cannot  be  sutured.  To  check  the  retraction  of  the  soft 
parts  of  stumps  left  open,  we  may  make  use  of  the 
method  established  long  ago  by  American  surgeons, 
that  is  to  say,  continuous  traction  on  the  skin.  Two 
strips  of  adhesive  plaster  of  suitable  dimensions  are 
applied  at  opposed  points  on  the  surface  of  the  limb, 
and  meet  on  a  small  piece  of  wood  ^  to  which  traction 
cords  are  attached.  A  weight  of  about  a  kilogram 
and  a  half  (about  3  lbs.  English)  is  sufficient  to  oppose 

^  "  Stirrup-piece  "  ( Tratis.). 


i84    TREATMENT   OF   INFECTED   WOUNDS 

the  retraction  of  the  soft  parts.  This  traction  in  no 
way  interferes  with  the  dressing  of  the  wound.  When 
steriHsation  is  complete  it  is  easy  to  suture  the  flaps 
which  are  now  in  the  same  position  as  though  the 
amputation  had  just  been  done. 

C.  Wound -closing  by  Suture. — Secondary  suture  of 
wounds  should  always  be  done  under  anaesthesia.  If 
the  skin  is  adherent  to  the  deeper  parts,  it  must  be  dis- 
sected up  to  a  sufficient  extent.  To  refresh  the  edges 
it  is  enough  to  remove  the  epithelial  margin  by  an 
incision  in  the  healthy  skin  a  millimetre  beyond  its 
external  border.  The  simple  excision  of  the  epithelial 
margin  will  suffice.  There  is  no  need  to  curette  the 
granulating  surface.  The  integuments  are  dissected  up 
for  a  distance  sufficient  to  ensure  good  adjustment  of 
the  edges.  Usually,  the  deep  parts  come  together 
spontaneously.  In  cases  where  it  may  be  of  service, 
deep  suturing  may  be  practised,  especially  sutures  of 
aponeurosis.  The  closure  is  usually  done  without 
drainage,  because  the  bacteriological  examination  has 
demonstrated  that  microbes  are  no  longer  existent  in 
the  wound. 

D.  Suture  of  Muscles  and  Nerves.—  Suturing  of 
muscles  and  tendons  is  carried  out  as  early  as  possible, 
in  order  to  avoid  retraction.  It  is  the  same  with  nerve 
suture.  Directly  the  wound  is  sterile,  the  operative 
conditions  become  the  same  as  in  aseptic  surgery. 

E.  Closure  of  Wounds  of  Compound  Fractures  or  Joint- 
Injuries. — In  the  majority  of  cases  it  is  possible  to  close 
a  compound  fracture  or  a  wounded  joint  in  the  same 
way  as  a  wound  of  the  soft  parts.  Should  there  be  a 
considerable    gap    in    the    bony    substance,    it    will    be 


THE   CLOSURE    OF   WOUNDS  185 

necessary  to  fill  it  up.  To  repair  these  seats  of  fracture 
we  use,  according  to  the  nature  of  the  case,  bone-grafting  ; 
or  we  fill  up  the  interval  with  fat.  muscular  tissue,  or 
some  inert  substance.  For  this  purpose  we  have  used 
Mosetig's  and  Beck's  pastes  {la  masse  de  Mosetig  et  la 
pdte  de  Becky  Fr.).  "  Beck's  paste  "  is  easier  to  handle 
than  "  Mosetig's  mass."  The  wound  is  prepared  in  the 
usual  manner,  that  is  to  say  it  is  relieved  of  its  epithelial 
margin  and  its  cavity  simply  dried  with  a  compress. 
Beck's  paste  is  then  injected  into  the  cavity,  which  is 
shut  off  by  aponeurotic  or  muscular  suture,  lastly  by 
.skin  sutures.  Wounds  of  joints  are  closed  in  the  same 
way.  Should  one  of  the  bony  extremities  contain  a 
large  cavity,  it  is  filled  up  in  the  manner  we  have  just 
pointed  out,  before  proceeding  to  the  closure  of  the 
articulation. 

III.  The  Use  of  Different  Methods  according 
TO  Wound  Conditions 

The  preceding  methods  are  chosen  according  to  the 
particular  conditions  presented  by  the  wounds  it  is 
desired  to  close.  These  wounds  may  be  divided  into 
different  categories  according  to  age  and  the  presence  or 
absence  of  previous  suppuration. 

1st.  Closure  of  Fresh  Wounds  which  have  become 
Sterile  before  the  Twelfth  Day. — Wounds  of  the  soft 
parts  may  be  closed  in  the  majority  of  cases — that  is  to 
say,  in  nearly  ninety  per  cent,  of  the  cases — before  the 
twelfth  day.  As,  at  this  period,  the  skin  is  movable 
on  the  deeper  structures,  bringing  together  of  the 
margins  of  the  wound  by  strapping  is  habitually  prac- 
tised.    Even  when  the  wound  is  deep  and  irregular  and 


i86     TREATMENT   OF   INFECTED   WOUNDS 

a  fracture  is  present,  the  operation  is  not  painful  and 
needs  no  anaesthetic.  Multiple  wounds  on  the  same 
patient  may  be  closed  one  after  another  as  they  become 
sterile.  If  the  skin  has  been  irritated  by  tincture  of 
iodine,  or  the  wounds  are  too  close  together  to  allow 
of  the  strapping  method  being  applied,  we  have  recourse 
to  suture,  and  if  there  is  loss  of  substance,  to  elastic 
traction.  The  method  of  suture  is  also  employed  in 
fresh  wounds,  when  one  has  to  unite  tendons,  muscles, 
or  nerves.  As  anaesthesia  is  necessary  for  suture  of 
nerves,  tendons,  or  muscles,  the  operation  is  terminated 
by  cutaneous  suture.  With  the  exception  of  these  cases, 
we  always  use  the  strapping  method,  which  has  the 
merit  of  bringing  together  the  deep  parts  of  wounds  as 
well  as  the  superficial  portions. 

2nd.  Closure  of  Fresh  Wounds  which  have  become 
Sterile  after  the  Twelfth  Day. — When  the  sterilisation 
of  the  wound  has  only  been  achieved  after  the  twelfth 
day,  it  is  no  longer  possible  to  use  the  strapping  method. 
Suture  is  then  practised.  As  the  wound  has  been  sub- 
jected from  the  outset  to  antiseptic  treatment,  and  it  is 
probable  that  the  cicatricial  tissue  contains  no  microbes, 
catgut  stitches  may  be  put  in  without  danger  of  reinfec- 
tion. In  wounds  which  have  remained  open  longer, 
careful  bringing  together  of  the  deeper  parts  is  carried 
out.  It  is  not  sufficient  merely  to  approximate  the 
skin. 

3rd.  Closui^e  of  Wounds  which  have  become  Sterile 
after  a  Period  of  Suppuration. — When  it  has  not  been 
possible  to  apply  the  treatment  from  the  beginning,  and 
the  wound  has  suppurated  for  a  longer  or  shorter  period, 
the  process  of  closure  must  be  a  little  different.     In  these 


THE    CLOSURE   OF  WOUNDS  187 

cases,  in  fact,  numerous  microbes  have  been  shut  in 
within  the  cicatricial  tissue.  Smears  show  that  the 
surface  of  the  wound  is  sterile,  but  they  yield  no  indica- 
tion as  to  the  state  of  the  deep  parts  which  are  already 
cicatrised.  It  is  therefore  important  to  bring  the  tissues 
together  without  injuring  them,  that  is  to  say,  without 
making  a  deep  dissection,  and  without  interstitial 
sutures.  The  scalpel  or  the  needle  when  traversing  a 
cicatrix  which  contains  microbes,  may  start  reinfection. 
We  must,  therefore,  be  content  with  bringing  together 
the  deep  parts  by  external  means,  and  only  suture 
skin.  Also,  one  may  operate  in  two  stages.  In  the 
first  stage,  dissect  up  the  tissues,  prepare  the  wound 
for  closure,  loosely  insert  sutures  ;  then  for  a  few  days 
continue  the  sterilisation  of  the  wound.  In  the  second 
stage,  close  the  wound.  By  taking  these  precautions, 
a  result  may  be  obtained  as  favourable  as  in  the  union 
of  wounds  which  have  never  suppurated. 


CHAPTER   VII 

THE    RESULTS 

The  method  should  only  be  credited  with  the  results 
obtained  by  application  in  its  entirety.  If  the  details  of 
the  technique  or  the  composition  of  the  antiseptic  be 
modified  at  hazard,  sterilisation  of  wounds  becomes 
impossible.  The  observations  made  by  surgeons  who 
have  used  Dakin's  solution  without  a  precise  technique 
should  therefore  be  looked  upon  as  valueless. 

I.  Results  of  the  Sterilisation  of  Wounds 

Sterilisation  of  a  wound  comes  to  pass  in  a  different 
manner  according  as  it  is  recent  or  old-standing  and  is 
associated  or  not  with  fracture. 

A.  Wounds  of  the  Soft  Parts. — From  the  month  of 
December,  191 5,  the  date  when  the  technique  was 
first  employed  under  its  actual  form  as  at  present,  all 
wounds  of  the  soft  parts  have  attained  surgical  asepsis. 
They  were  subjected  to  secondary  suture,  with  the 
exception  of  those  which  were  very  small  and  healed 
spontaneously,  and  those  which  were  accompanied  by 
so  great  a  loss  of  substance  that  they  could  not  be 
closed.  Wounds,  fresh,  phlegmonous,  gangrenous,  sup- 
purating, all  were  equally  capable  of  disinfection,  but 

188 


PLATE    III. 


Fig.  74. — Case  465.     Section  of  quadriceps,  3rd  day. 


Fig.  76. — Case  606.     Large  wound  of  forearm. 


Fig.  78. -Case  577.     Wound  of  knee,  5th  day. 

[^I'oface  page  li 


PLATE    IV 


Fic;.  75.— Case  465.       Suture,   7th  day. 


Fig.  77. — Case  606.      \\  uund  closed,  6th  day, 


Fro.  79. — Case  577.     Suture,  14th  day. 

ITofacc  Plafc  rif. 


THE    RESULTS  189 

the  rapidity  of  the  sterih'sation    depended   in  a  certain 
measure  on  the  state  of  the  infection. 

1st.  Fresh  Wounds. — When  the  treatment  of  wounds 
was  commenced  from  five  to  twenty-four  hours  after  the 
injury,  sterilisation  was  rapidly  produced.  Generally 
microbes  disappeared  from  the  fifth  to  the  twelfth  day  if 
the  wounds  contained  no  gangrenous  tissue.  The  fol- 
lowing, which  have  been  chosen  from  amongst  many 
similar  reports,  show  with  what  rapidity  a  large  wound 
can  be  disinfected  and  sutured. 

Case  465  suffered  from  a  large  shell-wound  traversing 
the  anterior  aspect  of  the  thigh  and  almost  completely 
dividing  the  quadriceps  femoris.  Three  and  a  half 
hours  after  the  receipt  of  the  injury,  the  wound  was 
laid  open  and  foreign  bodies  and  torn  muscular  tissue 
removed.  An  extensive  wound  resulted,  more  than  10 
centimetres  long  and  extending  from  one  side  of  the 
thigh  to  the  other  (Figs.  74  and  75).  At  the  end  of 
seven  days,  the  wound  was  surgically  sterile.  Then 
careful  suture  by  catgut  of  the  quadriceps  was  carried 
out  and  the  skin  closed  (Fig.  75).  It  healed  by 
first  intention,  and  shortly  afterwards  the  patient  walked 
normally. 

Case  315  was  operated  upon  twenty-three  hours  after 
having  received  multiple  shell-wounds,  of  which  two  were 
deep  in  the  buttock  The  most  extensive  of  the  wounds 
measured  after  cleaning-up  18  centimetres  long,  9  centi- 
metres wide,  and  8  centimetres  deep.  Sterilisation  of 
this  wound  was  slightly  retarded  by  the  presence  of 
gangrenous  tissue,  which  was  found  near  the  cutaneous 
margin  of  the  wound.  However,  after  five  clays,  the 
wound  became   surgically  sterile,  and    was   closed   with 


190     TREATMENT   OF    INFECTED   WOUNDS 

adhesive   plaster.     Nine   days  later,  the    strapping  was 
removed  and  the  wound  found  to  be  healed. 

Case  606 :  a  shell-wound  penetrated  the  forearm, 
went  through  the  epitrochlear  muscles  and  divided  the 
radial  (Fig.  76).     The  wound  was  closed  the  sixth  day 

(Fig.  77)- 

In  wounds  of  the  soft  parts,  sterilisation  is  almost 
always  rapidly  achieved.  Out  of  1 36  wounds  closed  during 
the  period — December,  191 5,  and  the  commencement  of 
January,  19 16 — 121  were  closed  before  the  twelfth  day. 
When  the  cases  were  operated  upon  during  the  first 
six  or  twelve  hours,  closure  was  practised  still  earlier. 
If  the  tissues  have  been  severely  torn  by  the  projectile, 
and  have  become  gangrenous  over  a  large  area,  sterili- 
sation is  attained  more  slowly.  In  Case  577  two  shell- 
wounds  had  lacerated  and  detached  all  the  tissues  of 
the  front  of  the  knee,  without  fracture  of  the  patella 
(Fig.  "j^).  The  projectiles  having  been  removed  from 
the  articulation,  the  wound  could  be  closed  the  fourteenth 
day  (Fig.  79).  In  wounds  sterile  over  almost  the 
whole  extent  of  their  surface,  microbes  often  persist 
near  the  aponeuroses  and  necrosed  tendons,  and  pre- 
vent closure  being  carried  out.  This  slow  elimination 
of  shreds  of  necrosed  tissue  was  the  commonest  cause 
of  delay  in  sterilisation  of  wounds  of  the  soft  parts. 
That  is  the  reason  why  thorough  surgical  cleansing  of 
the  wound  is  so  important.  In  cases  where  necrosed 
tissue  had  remained  for  a  long  period  on  the  surface 
of  the  wound,  suture  was  practised,  as  a  rule,  from 
the  fifteenth  to  the  twentieth  day. 

2nd.  Phlegmonous  and  Gangrenous  Wounds. — Cases 
arriving  later  at  the  hospital,  with  wounds  already  bearing 


THE   RESULTS  191 

evidence  of  phlegmon  or  gangrene,  were  treated  in  a 
similar  manner.  After  the  disappearance  of  serious 
infection,  many  injuries  could  be  sutured. 

Case  340,  with  multiple  shell-wounds,  was  operated 
upon  after  nineteen  hours.  Wounds  of  the  thighs  and 
legs  were  freely  laid  open,  shell -fragments  removed  and 
instillation  tubes  placed  in  the  tracks.  Three  of  the 
wounds  developed  along  normal  lines  and  were  closed 
on  the  ninth  day.  The  fourth,  situate  at  the  inferior  ex- 
tremity of  the  right  thigh,  suffered  a  grave  complication. 
The  projectile  had  opened  a  vein  in  the  popliteal  space, 
and  caused  a  haemorrhagic  infiltration  of  the  whole  of  the 
cellular  tissue  of  the  calf.  This  haematoma  had  remained 
undetected  at  the  time  of  operation.  But,  after  twenty- 
four  hours,  the  temperature  reached  40°  C.  (i03*5''  Fahr.). 
The  calf  and  the  popliteal  space  were  purple,  and  very 
painful.  The  inflamed  region  was  then  incised  from  the 
popliteal  space  to  the  lower  third  of  the  leg  (Fig. 
80).  At  the  end  of  eleven  days,  the  great  wound  had 
become  sterile,  and  the  temperature  came  down  from 
40°  to  ^7°  C.  (103-5''  to  98-5°  Fahr.).  Next,  along  the 
margins  of  the  wound  elastic  traction  was  applied,  for 
the  tissues  were  too  far  retracted  to  allow  of  immediate 
union.  Under  the  influence  of  elastic  traction,  the 
margins  of  the  wound  steadily  approached  each  other, 
and  united  three  days  later,  that  is  to  say,  twenty- 
one  days  after  the  infliction  of  the  injury  (Fig.  81). 
Sterilisation  came  about  more  slowly  than  in  an  ordinary 
wound.  However,  it  should  be  looked  upon  as  rapid, 
taking  into  consideration  the  gravity  and  extent  of  the 
infection. 

Similar  results  were  observed  in  cases  of  gangrenous 


192     TREATMENT   OF    INFECTED    WOUNDS 

infection.  Case  454  presented  fourteen  wounds  of  the 
lower  limbs,  due  to  the  explosion  of  a  grenade.  He  was 
operated  on  six  hours  after  the  injury.  All  fragments 
of  missile  were  removed,  and  each  wound  was  furnished 
with  an  instillation  tube,  with  the  sole  exception  of  a 
tiny  one  which  was  overlooked.  The  thirteen  wounds 
treated  antiseptically  developed  in  normal  fashion  and 
were  rapidly  closed.  But  the  wound  which  had  not  been 
treated  was  followed  by  a  serious  infective  complication. 
This  wound  was  on  the  external  aspect  of  the  right  leg. 
The  fragment  of  grenade  was  found  at  a  depth  of  two 
centimetres  in  the  long  peroneal  muscle.  The  track  had 
been  carefully  exposed  and  excised,  but  no  instillation 
tube  had  been  inserted.  Next  morning,  the  dressing 
had  an  unpleasant  odour,  and  the  calf  was  red,  tense, 
and  swollen.  Gas  escaped  from  the  orifice.  A  free 
incision  was  made  on  the  external  aspect,  and  it  was 
found  that  the  muscles  of  the  front  of  the  leg,  as  well  as 
the  lateral  peronei,  had  been  attacked  by  gas-producing 
gangrene  throughout  almost  the  whole  of  their  extent. 
Infection  had  clearly  started  from  the  non-irrigated  point. 
Instillation  tubes  were  placed  in  the  wound,  which  rapidly 
cleaned  up.  At  the  end  of  six  days,  the  temperature  of 
the  case  was  normal,  and  the  necrosed  tissues  in  a  fair 
way  towards  elimination.  After  a  second  period  of  six 
days,  the  wound  was  clean  and  red.  Some  microbes 
only  remained  near  the  extensor  tendons.  Twenty-eight 
days  after  the  injury,  the  wound  was  completely  closed. 
The  thirteen  other  wounds  had  been  able  to  be  sutured 
the  twelfth  day.  Hence  in  spite  of  the  serious  character 
of  the  infection,  sterilsiation  only  demanded  a  little  more 
than  double  the  normal  time. 


PLATE    V. 


Fig.  8o. — Case  340.     Large  infected  wound  of  calf,  nth  day. 


ti(j.  82.  -  Case  433.     Fracture  of  neck  of  hiuuerus,  15th  day, 


Fig.  84. — Case  594.     Shell-wound  of  knee  :  partial  fracture  of 
condyle,  6th  day. 

[  To  /ace  page  193. 


platp:  VI. 


Fig.  8i. — Case  340.     Same  wound,  the  2Tst  day. 


Fig.  83. — Case  433.     Suture,  lyth  day. 


Fig.  85. — Case  594.     Wound  became  sterile  the  i6thdayand 
was  closed  the  20th. 

ITo  face  Plate  V. 


THE   RESULTS  193 

3rd.  Suppui^ating  Wounds. — Wounds  which  are  already 
suppurating  when  brought  under  treatment  are  readily 
disinfected.  Surface  wounds,  even  when  suppuration  is 
abundant,  are  sterilised  in  a  few  days.  Usually,  when 
a  granulating  wound  is  washed  with  neutral  oleate  of 
soda,  and  treated  either  with  hypochlorite  or  chloramine 
paste,  microbes  disappear  completely  from  the  smears  in 
two  or  three  days. 

It  is  the  same  with  abscess  cavities.  When  a  tube 
is  placed  in  the  cavity  of  an  abscess,  and  the  liquid  can 
reach  every  portion  of  the  surface  of  the  walls,  sterilisa- 
tion takes  place  with  great  rapidity.  Then,  by  a  com- 
pression dressing,  the  walls  can  be  brought  together  and 
the  cavity  obliterated  in  a  very  short  time.  When  the 
wound  is  deep  and  irregular,  and  contains  necrotic 
tissue,  sterilisation  is  attained  more  slowly.  In  a  series 
of  fifty-nine  wounds,  aged  from  one  to  twenty-three  days 
at  the  commencement  of  treatment,  ninety- two  per  cent, 
were  closed  before  the  twenty-second  day.  Some  of 
these  wounds  were  sutured  the  fifth  day,  as  though  they 
had  been  fresh  wounds.  The  remaining  wounds — that 
is  to  say,  eight  per  cent. — were  sterilised  after  the 
twenty-second  day. 

We  may  therefore  say  that  all  wounds  of  soft  parts 
respond  to  treatment  by  becoming  sterile.  About  ninety 
per  cent,  of  both  fresh  and  suppurating  wounds  were 
closed  before  the  twentieth  day.  The  rest  were  dis- 
infected at  a  slower  rate,  but  all  attained  surgical  asepsis. 

B.  Compound  Fractures. — Results  varied  according  as 
treatment  was  corrtmenced  before  or  after  the  suppuration 


stage. 


1st.  Fresh  Fractures. — Experience  has  taught  us  that 

13 


194     TREATMENT   OF   INFECTED   WOUNDS 

from  the  point  of  view  of  results,  fractures  should  be 
divided  into  two  classes  :  in  one  class,  short  bones,  the 
smaller  long  bones,  flat  bones,  radius,  ulna  and  fibula  ; 
in  the  other  class,  fractures  of  humerus,  tibia  and  femur. 

Since  the  month  of  December,  191 5,  we  have  suc- 
ceeded in  sterilising,  in  a  satisfactory  manner  from  the 
surgical  point  of  view,  all  compound  fractures  of  the 
smaller  long  bones,  short  bones  and  flat  bones  which 
arrived  at  the  hospital  from  five  to  twenty-four  hours 
after  the  infliction  of  the  injury,  with  the  exception  of 
fractures  of  the  jaw  communicating  with  the  mouth.  In 
the  greater  number  of  the  cases,  fractures  of  metacarpus 
and  metatarsus,  deep  wounds  of  ankle  or  wrist  with 
laying  open  of  several  articulations,  have  been  closed. 
Fractures  of  the  patella  have  yielded  similar  results. 
We  may  conclude  that  these  fractures  from  the  sterili- 
sation point  of  view  behave  like  wounds  of  the  soft 
parts. 

In  the  majority  of  cases,  sterilisation  of  fractures  of 
the  humerus,  tibia  and  femur  has  been  obtained. 

{a)  Fractures  of  the  humerus  consolidated  without 
its  being  necessary  to  make  an  extensive  resection.  The 
possibility  of  sterilising  the  seat  of  fracture  allowed  the 
preservation  of  splinters  of  orthopaedic  value.  The 
greater  number  of  fractures  of  the  humerus,  whether 
implicating  or  not  the  articular  surfaces,  have  been  able 
to  be  sterilised  and  quickly  closed.  In  highly  com- 
minuted fractures,  bone  fragments  which  were  entirely 
free  were  removed,  and  after  sterilisation  of  the  seat  of 
fracture,  replaced  by  Beck's  paste.  Here  is  an  example 
of  this  form  of  treatment. 

Case  321   came  to  hospital  four  hours  after  having 


THE    RESULTS  i95 

received  a  shell  wound  in  the  right  arm.  He  presented 
an  extremely  comminuted  fracture  of  the  superior 
extremity  of  the  humerus  directly  below  the  head.  The 
superior  orifice  was  laid  open  freely  and  cleansed  care- 
fully. A  counter-opening  on  the  anterior  surface  of  the 
arm  was  made,  to  remove  the  projectile,  and  to  take 
away  a  large  number  of  small  fragments  of  bone  which 
were  lying  free.  The  medullary  canal  had  to  be  curetted 
because  several  splinters  had  been  projected  therein. 
There  resulted  an  extensive  loss  of  substance  ;  three 
instillation  tubes  were  introduced.  After  twelve  days 
the  patient's  temperature  was  normal,  and  the  surface 
of  the  wound  no  longer  yielded  microbes  to  the  test. 
On  the  fifteenth  day  the  loss  of  bony  substance  was 
made  good  by  Beck's  paste,  and  the  wound  was  closed 
by  a  series  of  intermuscular  sutures,  and  a  line  of 
cutaneous  stitches  (Fig.  S6).  The  twenty-first  day 
stitches  were  removed.  Union  was  perfect.  The  man 
recovered  all  the  movements  of  the  limb. 

In  non-comminuted  fractures  of  the  humerus,  suturing 
was  generally  done  from  the  tenth  to  the  fifteenth  day, 
and  consolidation  was  brought  about  as  rapidly  as  in  a 
simple  fracture. 

(d)  In  fractures  of  the  tibia,  surgical  asepsis  was 
attained  in  a  more  leisurely  fashion.  Besides,  the  loss 
of  integumental  substance  was  often  too  great  to  allow 
of  the  margins  of  the  wound  being  brought  together. 
Then  we  had  to  be  content  with  sterilising  the  seat  of 
fracture  and  awaiting  closure  by  granulation. 

In  this  manner  consolidation  without  a  sinus  of  highly 
comminuted  fractures  may  be  obtained.  Case  494  was 
injured  in  the  middle  third  of  the  leg  by  a  shell  which 


196     TREATMENT   OF    INFECTED   WOUNDS 

fractured  the  tibia.  In  the  course  of  the  first  surgical 
interference  by  MM.  Hornus  and  Perrin,  only  the 
smallest  of  the  free  bony  splinters  were  removed,  the 
larger  fragments  being  left  lying  between  the  osseous 
extremities.  For  nine  days,  Dakin's  solution  was 
instilled  every  two  hours.  When  the  case  was  brought 
to  the  hospital,  ten  days  after  receipt  of  the  injury,  there 


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Fig.  86. — Fracture  of  humerus,  fiUing- 
in  with  Beck's  paste.     Case  321. 


Fig.    87.  — Fracture     of 
tibia.     Case  494. 


were  still  ten  microbes  per  microscope-field,  but  the 
wound  bore  an  excellent  appearance,  and  the  tissues 
presented  neither  redness  nor  swelling.  The  only  opera- 
tive interference  was  to  blunt  the  point  of  a  splinter 
which  projected  into  the  wound.  A  month  after  the 
injury,  all  the  bony  fragments  had  been  covered  by 
granulations,  and  the  instillation  tubes  were  discontinued. 
By   reason    of    the    extensive    loss    of    skin    substance 


THE    RESULTS 


197 


cicatrisation  came  about  slowly,  but  two  months  after 
the  injury,  healing  was  complete  without  a  sinus 
(Fig.  8S). 

The  conservation  of  fragments  of  bone  is  of  great 
importance  from  the  point  of  view  of  ulterior  function 
of  the  limb.     In  sterilising  splinters  more  or  less  denudecl, 


Fig.  88.— Same  frac- 
ture healed.  Case 
494- 


Fig.  89. — SuppuratinjE^  frac- 
ture of  the  upper  part  of 
the  tibia.     Case  516. 


we  succeeded  in  making  use  of  them,  and  in  obtaining 
consolidation  of  the  bone.  In  case  516,  a  shell  had 
caused  a  serious  fracture  of  the  tibia,  at  the  level  of  the 
junction  of  epiphysis  and  diaphysis.  The  internal  two- 
thirds  of  the  bone  had  been  destroyed,  while  the  external 
portion  presented  two  long  splinters  almost  completely 
denuded  of  periosteum.     They  were  kept,  nevertheless, 


198     TREATMENT    OF    INFECTED    WOUNDS 

because  their  ablation  would  have  shortened  the  bone  by 
seven  or  eight  centimetres  (Fig.  89) :  the  anterior  tibial 
nerve  and  vessels  had  been  severed.  The  wound  rapidly 
sterilised,  but  by  reason  of  loss  of  substance  it  was 
impossible  to  close  it.  Seventeen  days  after  the  injury, 
there  was  to  be  seen  at  the  upper  part  of  the  tibia  a 
large  wound,  at  the  bottom  of  which  was  a  bony  cavity 
the  size  of  a  small  egg.  This  wound  no  longer  contained 
microbes.  It  was  then  filled  with  a  paste  containing 
chloramine,  under  which  asepsis  was  maintained.  Im- 
mediately it  was  filled  up  by  granulations,  whose  surface 
became  covered  with  epidermis.  Cicatrisation  was  com- 
plete three  months  after  the  infliction  of  the  injur}^ 
The  fracture  was  almost  completely  consolidated,  with- 
out either  reinfection  or  elimination  of  sequestra  being 
produced. 

In  some  cases  it  is  possible  to  close  fractures  of  the 
leg.  In  Case  627  the  fracture  of  the  tibia  above  the 
malleoli  was  found  to  be  sterile  ten  days  after  the  inflic- 
tion of  the  injury  (Fig.  90).  The  eleventh  day  it  was 
completely  closed,  and  on  the  sixteenth  day  the  wound 
had  healed  by  first  intention. 

(c)  Even  highly  comminuted  fractures  of  the  thigh 
are  sterilised  in  such  a  manner  that  in  about  half  the 
cases  suture  can  be  practised.  The  degree  of  asepsis 
obtained  in  the  non-sutured  cases  was  sufficient  to  allow 
the  seat  of  fracture  to  be  isolated  from  the  external 
wounds.  Consolidation  was  produced  almost  as  if  a 
simple  fracture  had  been  in  question.  In  none  of  the 
cases  which  reached  us  during  the  first  twenty-four 
hours,  did  a  sinus  persist.  Infected  fractures  of  the 
femur  could  be  closed  the  15th,  23rd,  and  the  25th  day. 


THE   RESULTS 


199 


Case  560,  aged  42  years,  arrived  at  the  hospital 
seven  hours  after  having  been  struck  by  a  shot  which 
produced  an  extremely  comminuted  fracture  of  the  left 
thigh.  The  diaphysis  of  the  femur  had  been  broken  at 
the  level  of  its  middle  third  into  multiple  fragments 
(Fig.  91).     The  orifice  of  entry  of  the  missile,  which  was 


Fig.  90. — Fracture  of  the  libia. 
Case  627. 


Fig.  91. — Fracture  of  the  femur.    Case 
560. 


internal,  was  very  freely  laid  open,  the  contused  muscular 
tissue  was  excised,  and  only  two  small  splinters,  which 
happened  to  be  completely  free,  were  removed.  Four 
instillation  tubes  were  placed  in  the  seat  of  fracture. 
The  temperature  never  rose  above  38'  C.  (100"  Fahr.), 
during  the  first  four  days,  then  steadily  dropped  and 
becanie  normal.     The  number  of  microbes,  which  the 


200     TREATMENT   OF   INFECTED    WOUNDS 

second  day  was  30  per  microscope  field,  diminished  to 
one  the  13th  day.  The  15th  day  the  wound  was  herme- 
tically sealed  by  silkworm  gut  {crins  de  Florence,  Fr.). 
Union  took  place  by  first  intention.  The  fracture  was 
firm  on  the  47th  day. 

Another  case,  No.  495,  aged  29  years,  had  received  a 
wound  from  the  explosion  of  a  mine  which  fractured  the 
right  femur  at  the  junction  of  the  lower  with  the  middle 
third.  Some  hours  afterwards  at  the  "  ambulance "  of 
V ,  MM.  Hornus  and  Perrin  removed  some  frag- 
ments and  the  foreign  body,  cleaned  up  the  contused 
muscles,  and  placed  conducting  tubes  for  antiseptic 
liquid  in  the  seat  of  fracture.  The  23rd  da)', 
microbes  having  disappeared  from  the  secretions,  the 
wound  was  closed  with  silkworm  gut.  At  this  date 
the  case  was  brought  to  us  (Fig.  92).  Union  of  the 
edges  of  the  wound  took  place  by  first  intention.  Con- 
solidation was  attained,  and-  the  patient  walked  on  the 
43rd  day.  There  was  three  centimetres  of  shortening, 
and  the  knee  possessed  its  normal  mobility. 

Case  493,  aged  38  years,  had  a  fracture  of  the  right 
femur   caused   by   shrapnel    (Fig.   93).      He   was    first 

treated   at    the    "  ambulance "    of  V ,    where    MM. 

Hornus  and  Perrin  removed  the  projectile  and  some 
small  splinters.  Like  the  preceding,  the  wound  was 
irrigated  by  means  of  Dakin's  solution.  After  seven 
days  he  was  sent  to  Compiegne.  The  temperature 
was  37'  C.  (98*5''  Fahr.),  the  wound  was  a  healthy  red 
and  presented  no  sign  of  suppuration,  the  surrounding 
integuments  were  supple  and  free  from  tenderness.  At 
this  stage,  the  number  of  microbes  was  about  twenty 
per  microscope  field.     On  the  23rd  day  it  had  dropped 


THE    RESULTS 


20 1 


to  one  per  three  fields.  The  wound  was  closed  the  25th 
day  by  silkworm  gut,  and  healed  by  first  intention. 
Consolidation  was  complete  44  days  after  the  infliction 
of  the  injury. 

The  number  of  fractures  of  the  thigh  treated  by  us 
was  very  limited.  But  there  is  no  doubt  that  similar 
results  can  be  obtained  when  fresh  compound  fractures 


Fig.  92. — Comminuted  frac- 
ture of  femur.     Case  495. 


Fig,  93. — Fracture  of  femur. 
Case  493. 


are  treated  by  methods  similar  to  ours.  Recently  M. 
Hornus  treated,  in  a  hospital  ("  ambulance,"  Fr.)  of 
the  first  line,  thirteen  cases  of  compound  fracture  of 
thigh.  After  four  or  five  days  the  cases  had  a  normal 
temperature  and  no  suppuration.  In  eleven  cases,  secon- 
dary suture  was  practised.  We  have  seen  also,  with  M. 
Depage  at  the  "  ambulance "  of  La   Panne,  fractures  of 


202     TREATMENT   OF   INFECTED   WOUNDS 

the  thigh  which  had  attained  surgical  asepsis  and  been 
closed. 

It  appears,  therefore,  quite  evident,  that  in  fractures 
of  the  thigh,  and  with  still  more  reason  in  fractures  of 
the  tibia  and  hunierus,  it  is  quite  possible  to  avoid  sup- 
puration while  making  very  limited  resections  {esquillec- 
tojnies^  Fr.).  Consolidation  comes  about  rapidly,  and 
cases  are  protected  at  the  same  time  against  pseudar- 
throsis  and  the  interminable  suppuration  which  so  often 
follow  compound  fractures  treated  by  the  ordinary 
methods. 

2nd.  Fractures  accompanied  by  Wounds  of  Joints. — 
When  a  wound  was  associated  with  the  opening  of  an 
articulation,  results  differing  according  to  the  region 
were  observed.  When  the  lesion  was  limited  to  synovial 
membranes  or  to  the  edges  of  the  articular  condyles, 
arthrotomy  followed  by  disinfection  of  the  seat  of 
fracture  permitted  the  osseous  extremities  to  be  retained. 
Often  functional  integrity  remained  complete.  The 
scope  of  simple  arthrotomy  could  be  enlarged,  and  the 
number  of  resections  diminished. 

In  the  cases  of  deeper  osseous  lesions  and  more 
extensive  fracture  of  the  articular  condyles,  we  have 
also  been  able  to  avoid  resection,  and  to  preserv^e  all 
the  movements  of  the  articulation.  Here  are  two 
examples  of  compound  fractures  of  the  inferior  ex- 
tremity of  the  humerus  completely  restored  by  sterilisa- 
tion of  the  wound. 

Case  433,  aged  25  years,  had  a  fracture  of  the  neck 
of  the  humerus,  due  to  a  fragment  of  shell  which  remained 
in  the  joint.  Four  hours  after  the  infliction  of  the  injury, 
the  orifice  was  laid  open  freely,  the  walls  of  the  track 


THE    RESULTS 


203 


cleaned,  and  a  resection  performed,  limited  to  the 
detached  fragments  of  bone.  After  the  missile  was 
removed,  tubes  were  placed  in  the  seat  of  fracture. 
After  fifteen  days  (Fig.  82)  sterilisation  was  attained, 
and  two  days  later  the  joint  was  closed  with  silkworm 
gut  (Fig.  83).  Union  took  place  by  first  intention. 
The  twenty-fifth  day  movements  of  the  joint  were 
begun.  The  functions  of  the  articulation  were  re- 
established completely. 

Case  497  had  a  shell  wound  of  the  right  elbow  which 
fractured  the  humerus,  separating  the  epicondyle  and 
part  of  the  condyle  of  the  humerus. 
This  case  was  treated  at  the  "  ambu- 
lance de  V "  by   MM.   Hornus 

and  Perrin,  who  were  content  with 
sterilising  the  large  wound  by 
means  of  tubes  going  down  to  the 
seat  of  fracture.  In  fifteen  days 
the  wound  was  sterile.  It  was 
sutured  the  sixteenth  day  with  silk- 
worm gut,  and  united  by  first  in- 
tention (Fig.  94).  The  movements 
of  the  elbow  were  re-established 
almost  completely.  There  remained 
only  a  slight  limitation  of  exten- 
sion. 

In  wounds  of  the  knee-joint  results  were  observed 
comparable  to  a  certain  extent  with  those  obtained  in 
lesions  of  the  elbow.  In  those  cases  where  the  anato- 
mical conditions  permitted,  we  have  endeavoured  to 
sterilise  the  articulation  in  such  a  way  as  to  retain  the 
normal  movements. 


Fig.  94. — Fracture  of 
condyle  of  humerus. 
Case  497. 


204    TREATMENT   OF   INFECTED   WOUNDS 

Case   472    had   multiple  wounds   of  the   soft  parts, 
which  were  cleaned  and  disinfected,  and  a  wound  of  the 
right  knee  with  injury  to  the  external  condyle.     A  piece 
of  a  grenade  had  penetrated  the  external  surface  of  the 
knee,  traversed  the  synovial  membranes,  and  lodged  in 
the  thickness  of  the  condyle.     The  aperture  of  entrance 
was  freely  laid  open,  the  walls  of  the  track'  resected,  the 
projectile  extracted,  and  the  tunnel  in  the  bone  carefully 
curetted.     The  articular  cavity  was  then  dried  and  shut 
off  by  a  compress  placed  beneath  and  within  the  damaged 
condyle,   and    an    instillation    tube    introduced   to   the 
bottom  of    the  bony  track.     The  wound  rapidly  cica- 
trised.    The  eighth  day  the  compress  used  for  "  shutting 
off"  was  removed,  and  on  the  twelfth  day  the  articula- 
tion was  closed.     Union  by  first  intention  followed,  and 
passive   movements  were  commenced  on  the  thirteenth 
day.     The  movements  of  the   joint    were   so   perfectly 
restored   that  the  patient  walked  in  a  normal  manner 
when  he  went  out  of  the  hospital. 

Case  289  was  operated  upon  twenty-four  hours  after 
having  received  a  shell-wound  which  broke  the   patella 
into  fragments  and  displaced  the  condyles  of  the  femur 
in    an    anterior   direction    without    their   fracture.     The 
contused  soft  parts  were  carefully  cleansed  and  all  the 
fragments  of  the  patella  removed  ;  the  character  of  the 
fragments  suggested  those  of  an  explosion.     A  compress 
was  placed  in  front  of  the  inter-articular  line,  and  two 
instillation  tubes  were  placed  in  the  cul-de-sac  of  the 
quadriceps  and  in  the  patella  fossa.     The  temperature, 
which  was  39*9"  C.  (i02*2''  Fahr.)  the  day  of  arrival,  fell 
by  the  fourth  day  to  37-5°  C.  (99''  Fahr.).      Similarly, 
bacilli  and  cocci  which  were  numerous  in  the  smears  were 


THE    RESULTS  205 

reduced  by  the  seventh  day  to  one  per  five  or  six  fields 
of  the  microscope.  The  wound  was  then  closed  by 
elastic  traction.  Cicatrisation  was  complete  by  the 
fifteenth  day,  and  passive  movements  of  the  joint 
commenced. 

Case  594  had  a  shell-wound  of  the  knee  with  partial 
fracture  of  the  external  condyle  of  the  femur.  The 
wound,  which  was  still  infected  the  sixth  day  (Fig.  84), 
became  sterile  the  fourteenth  day,  and  was  sutured  the 
twentieth  (Fig.  85). 

In  the  following  case,  despite  the  very  extensive 
lesions,  we  were  able  to  save  the  lower  extremity  of  the 
femur. 

Case  106,  aged  22  years,  had  had  a  smashing-up 
of  the  lower  epiphysis  of  the  right  femur,  fracture  of 
the  left  patella,  and  a  large  wound  of  the  hand.  He 
reached  hospital  in  a  grave  condition  of  shock  some  ten 
hours  after  the  infliction  of  the  injury.  Immediate 
transfusion  was  resorted  to,  and  interference  limited  to 
placing  instillation  tubes  in  the  crevices  between  the 
bony  fragments  which  represented  the  smashed  femoral 
condyles.  Into  the  seat  of  fracture  was  instilled  para- 
toluene  sulphochloramine,  3  per  cent.  His  temperature 
never  rose  above  39"^  C.  (102"  Fahr.),  and  became  practi- 
cally normal  at  the  end  of  a  month.  His  general  condi- 
tion remained  good,  and  his  hospital  stay  ended  by  healing 
with  an  ankylosed  knee  (Fig.  95).  In  this  case  no 
surgical  interference  was  practised  at  the  outset  because 
of  the  extreme  gravity  of  the  case.  However,  in  spite  of 
the  extent  of  the  anatomical  lesions  of  the  knee,  recovery 
took  place  without  the  patient's  condition  causing  a 
moment's  anxiety. 


2o6     TREATMENT    OF    INFECTED    WOUNDS 


3rd.  Suppurating  Fractures. — The  greater  number  of 
compound  fractures  treated  by  the  usual  methods  sup- 
purate more  or  less  abundantly.  We  have  examined 
the  effects  of  chemical  sterilisation  on  a  score  of  fractures 
which  had  been  previously  treated  in  other  hospitals, 
for  periods  varying  from  two  to  forty-six  days.  Sup- 
puration generally  disappeared  in  from  one  to  four  days 


Fig.  95. — Smash  of  extremity  of 
femur.     Case  106. 


Fig.  96. — Sup- 
jjurating  frac- 
ture of  hume- 
rus.   Case  624. 


after  the  commencement  of  treatment.  But  the  bac- 
teriological curves  show  that,  after  the  disappearance  of 
the  pus,  wounds  evolve  in  different  ways  according  to 
the  localisation  of  the  infection. 

(a)  In  the  first  category  of  cases,  the  number  of 
microbes  rapidly  lessens  after  the  establishment  of  instil- 
lation, and  in  a  few  days  reaches  one  per  five  or  six 
fields.     When    the  curve   presents   this  aspect,  there  is 


THE    RESULTS  207 

in  the  depths  of  the  wound  neither  infected  fragment 
nor  focus  of  osteo- myelitis,  and  in  spite  of  the  suppura- 
tion, the  seat  of  fracture  becomes  sterile  as  though  a 
newly  inflicted  fracture  were  being  dealt  with.  We  have 
observed  this  result  in  several  fractures  of  the  humerus, 
radius,  ulna,  and  some  of  the  smaller  bones.  Here  are 
two  examples  of  this  development. 

Case  624,  aged  34  years,  entered  hospital  twelve 
days  after  a  fracture  of  humerus  from  shell-wound 
(Fig.  96).  He  had  been  operated  on  a  few  hours  after 
the  injury.  The  left  arm  had  two  wounds,  one  internal, 
the  other  external.  A  big  drainage  tube  traversed  the 
seat  of  fracture.  The  limb  was  surrounded  by  a  dressing 
stained  with  blue  pus.  The  wounds  were  plugged  with 
iodoform  gauze,  behind  which  was  found  a  large  quantity 
of  pus.  The  drainage  tube  was  removed,  and  instillation 
tubes  inserted  into  both  wounds  as  far  as  the  seat  of 
fracture.  The  next  day  the  blue  pus  had,  clinically 
speaking,  disappeared.  The  following  day  the  wounds 
had  taken  on  the  usual  red  appearance.  The  microbes, 
which  were  innumerable  the  first  day,  had  completely 
disappeared  ten  days  later.  The  two  wounds  were 
sutured  twelve  days  after  the  entry  of  the  patient  into 
hospital.  They  united  by  first  intention.  Two  other 
cases  with  similar  lesions,  at  the  same  period,  were 
sutured  with  like  results. 

Case  626  presented  a  semi-section  of  the  upper 
portion  of  the  forearm,  with  smashing-up  of  the  two 
bones.  He  had  undergone  operation  in  an  "  ambulance  " 
at  the  front,  and  arrived  in  hospital  nine  days  later.  The 
wounds  were  suppurating  abundantly,  the  forearm  was 
a  little  swollen  and  very  painful.     The  dressings  were 


2o8     TREATMENT    OF    INFECTED   WOUNDS 

soaked  in  a  large  quantity  of  blue  pus.  On  the  surface 
of  the  wound  remained  fragments  of  gangrenous  tissue. 
The  wound  was  dressed  with  a  paste  containing  i'5  per 
cent,  of  chloramine.  Two  days  later  the  blue  pus  had 
disappeared.  After  three  days  the  swelling  of  the  fore- 
arm was  gone  and  the  wound  was  commencing  to  "  clean 
up."  But  the  microbes  were  still  innumerable.  The 
wound  only  became  surgically  aseptic  after  the  lapse  of 
a  fortnight.  It  was  sutured  the  twentieth  day,  and 
healed  by  first  intention. 

Case  6 1 8,  aged  31  years,  had  a  splintered  fracture 
of  the  femur  through  the  trochanters,  due  to  a  projectile 
which  had  penetrated  the  antero-external  aspect  of  the 
thigh.  He  was  operated  on  in  an  "  ambulance  "  at  the 
front  eight  hours  afterwards.  He  arrived  at  hospital 
twelve  days  later.  The  limb  was  put  up  in  plaster  with 
a  "  window."  A  large  rubber  drainage  tube  which  was 
found  in  the  wound  was  removed,  and  replaced  by  three 
perforated  instillation  tubes.  The  patient's  condition 
was  good.  But  the  region  of  the  hip  was  painful  and 
a  little  swollen.  The  wound  presented  scanty  secretion 
which  did  not  yield  more  than  ten  to  twenty  microbes 
per  microscope-field.  Seven  days  after  the  arrival  of 
the  case  at  the  hospital  the  wounds  were  almost  aseptic. 
Then  the  two  instillation  tubes  were  removed  and  the 
wound  filled  up  to  the  level  of  the  seat  of  fracture  with 
chloramine  paste.  The  wound  became  aseptic.  We 
waited  until  the  twentieth  day  before  closing  it.  Union 
took  place  by  first  intention  (Fig.  97). 

{b)  In  the  second  category  of  cases,  the  number  of 
microbes  contained  in  the  secretions  diminished  rapidly 
at  first,  then  at  the  end  of  a  few  days  the  bacteriological 


THE   RESULTS 


J09 


curve  becomes  a  horizontal  line.  The  quantity  of 
microbes  observed  in  each  field  varied  from  about  five 
to  fifty.  But  they  never  got  below  one.  When  the 
microbial  curve  forms  a  plateau  at  the  level  of  or  above 
the  line  indicating  five  microbes  per  field,  experience  has 
shown  that  there  exists  in  the  depths  of  the  wound 
either  a  sequestrum  or  a  patch  of  osteitis  which  would 
justify  surgical  interference.     Even  in  those  cases  where 


Fig.  97.— Trans-trochanterian  fracture  of  femur.     Case  618. 

complete  sterilisation  could  only  be  obtained  by  resorting 
to  a  secondary  "  cleaning-up,"  suppuration  dried  up  in  a 
few  days  and  the  general  condition  of  the  patients 
changed  greatly  for  the  better. 

The  following  example  demonstrates  how  the  dura- 
tion of  treatment  may  be  lengthened  if  a  compound 
fracture  of  the  thigh  be  allowed  to  suppurate  even 
slightly. 

14 


2IO     TREATMENT   OF   INFECTED    WOUNDS 

Case  496,  aged  25  years,  arrived  at  the  hospital 
forty-two  days  after  having  received  a  shell  wound  which 
had  caused  a  highly  comminuted  fracture  of  the  right 
thigh.  A  few  drops  of  pus  came  from  the  opening. 
Instillation  tubes  were  put  in  position  and  the  pus  dis- 
appeared almost  completely.  But  on  the  surface  of  the 
track  four  or  five  microbes  per  field  of  the  microscope 
persisted.  Four  months  later,  slight  sero-purulent  oozing 
came  from  the  seat  of  fracture,  from  which  numerous 
fragments  were  removed.  Two  months  later  the  sinus 
was  still  not  closed.  This  persistence  of  suppuration 
shows  how  important  it  is  to  sterilise  these  compound 
fractures  at  the  outset,  to  the  degree  when  they  contain 
no  microbes  at  all.  In  the  present  case  the  fracture  had 
consolidated  rapidly  enough.  But  care  had  not  been 
taken  to  dry  up  the  suppuration  in  an  early  stage.  The 
consequence  was  that  the  patient,  instead  of  recovering 
as  though  he  had  only  a  simple  fracture,  still  suffered 
from  a  small  sinus  six  months  after  the  infliction  of  the 
injury. 

When  fractures  are  treated  early,  even  if  they  are 
freely  suppurating,  the  results  observed  are  much  better. 

Case  642,  aged  21  years,  had  a  shell  wound  causing 
fracture  of  the  middle  of  the  right  femur.  The  projectile 
was  extracted  in  an  "  ambulance  "  at  the  front  five  hours 
after  the  injury.  Two  large  drainage  tubes  were  placed 
in  the  posterior  wound  and  the  end  of  one  of  these  tubes 
came  out  by  the  internal  wound.  A  long  anterior  wound 
was  plugged  with  gauze  compresses  tightly  packed  in, 
and  almost  completely  closed  by  suture  over  the  com- 
presses. The  result  of  this  therapeusis  was  disastrous. 
When  we  received    the  case  at   the  hospital    two  days 


THE    RESULTS  211 

after  the  operation  the  thigh  was  swollen  and  very 
painful.  The  plaster  apparatus  and  the  dressings  were 
soaked  in  an  extremely  foetid  discharge.  The  stitches 
were  immediately  removed.  The  tissues  were  found 
almost  black,  covered  with  sanious  pus,  stinking. 
Microbes  in  infinite  number  were  contained  in  these 
secretions.  Three  irrigating  tubes  were  placed  in  the 
posterior  wound,  three  in  the  anterior,  and  four  in  the 
internal  wound.  Next  day  the  bad  smell  had  quite 
gone,  suppuration  likewise.  The  following  day  the 
general  condition  of  the  patient  was  much  improved, 
although  the  thigh  was  still  swollen.  Six  days  later, 
the  swelling  of  the  thigh  had  greatly  diminished,  and 
the  wound  had  become  red.  Eleven  days  afterwards, 
some  of  the  tubes  were  removed,  for  healing  was  pro- 
ceeding rapidly.  Twenty-three  days  after  the  patient's 
entrance  into  hospital,  the  internal  wound  was  isolated 
from  the  seat  of  fracture,  and  the  posterior  and  external 
only  communicated  with  it  by  a  narrow  track.  Two  days 
later,  two  of  the  wounds  were  sterile,  and  the  third  only 
contained  a  few  microbes.  The  evolution  of  this  frac- 
ture was  then  comparable,  in  a  certain  measure,  with 
that  of  a  fresh  compound  fracture  treated  before  the 
onset  of  suppuration. 

In  highly  comminuted  fractures,  it  was  usually 
impossible  to  disinfect  the  wound  without  surgical 
interference. 

Case  617,  aged  28,  had  received  a  torpedo  wound 
which  had  pounded  up  the  tibia  at  its  upper  part.  After 
some  hours  it  was  operated  upon  in  an  "ambulance 
chirurgicale,"  where  free  splinters  were  removed,  and 
where,  very  wisely,  they  had  carefully  preserved  several 


212     TREATAIENT   OF    INFECTED   WOUNDS 

large  plates  of  bone  adherent  to  the  periosteum  of  the 
internal  surface.  The  seat  of  fracture  was  disinfected 
and  dressed  with  ether,  and  the  limb  immobilised  in 
a  metallic  gutter-splint.  This  patient  arrived  at  the 
hospital  three  days  later.  The  limb  looked  well  and 
the  temperature  was  38*5°  C.  (ioi°Fahr.).  But  the  sur- 
face of  the  bone  was  dark  in  colour  and  extremely  in- 
fected. Examination  of  the  pus  showed  that  the 
microbes  there  were  innumerable.  Two  instillation 
tubes  were  placed  in  the  cavity,  and  after  four  days  the 
temperature  fell.  Pain  and  swelling  of  the  limb  also 
disappeared.  Nevertheless,  after  twenty-five  days  the 
number  of  microbes  gathered  from  the  surface  of  the 
wound  was  still  high.  Surgical  cleansing  of  the  surface 
of  the  bony  cavity  was  carried  out,  and  several  small 
sequestra  removed,  preserving  the  periosteum.  Instilla- 
tion tubes  were  placed  in  the  cavity.  Sharply  the 
microbial  curve  dropped,  and  reached  the  level  which 
indicates  surgical  asepsis. 

Even  in  those  cases  where  the  extent  of  the  lesions 
and  the  gravity  of  the  general  condition  do  not  permit 
of  an  integral  application  of  the  method,  still  we  can 
obtain  sufficient  disinfection  to  transform  both  the  local 
and  general  conditions  of  the  patient. 

Case  635,  aged  34  years,  had  a  large  wound  of 
the  right  thigh  with  fracture  of  the  femur.  He  was 
operated  upon  in  an  "  ambulance,"  where  a  plaster 
apparatus  had  been  applied.  But  a  very  abundant 
suppuration  set  in,  and  during  the  weeks  which  followed, 
he  had  seven  secondary  haemorrhages.  This  patient 
reached  us  forty-six  days  after  the  injury.  He  was  in 
a  very  serious  condition.    The  thigh  presented  an  antero- 


THE    RESULTS  213 

internal  wound  and  a  posterior  wound.  The  denuded 
extremity  of  the  superior  fragment  stuck  out  into  the 
wound.  Pus  in  large  quantity  poured  from  the  seat 
of  fracture,  and  rapidly  soiled  the  dressings.  The 
patient  was  very  depressed;  his  evening  temperature 
was  38*5°  C.  (lOi*^  Fahr.).  The  urine  contained  albumen. 
Haemoglobin  was  reduced  to  30  per  cent,  of  its  normal 
quantity.  Systolic  arterial  pressure  was  I2'5  and 
diastolic  pressure  8.  In  addition  the  patient  suffered 
from  intractable  diarrhoea.  Because  of  the  gravity  of 
the  general  condition,  we  limited  our  action  to  slipping 
four  instillation  tubes  along  the  bony  fragments  in 
the  seat  of  fracture.  But  the  whole  of  the  infected 
region  could  not  be  reached  in  this  manner.  As  the 
patient  was  not  in  a  condition  to  stand  an  incision, 
we  were  content  to  irrigate  those  parts  of  the  infected 
area  we  could  reach.  At  the  end  of  a  week  the 
general  condition  had  improved,  and  suppuration  had 
almost  completely  disappeared.  But  the  diarrhoea 
changed  into  dysentery,  and  the  general  condition 
changed  for  the  worse.  By  way  of  compensation  the 
local  condition  rapidly  improved.  Granulations  covered 
the  bare  bony  surfaces.  Pain  had  disappeared.  But 
microbes  remained  in  considerable  numbers.  Twenty 
days  after  the  arrival  of  the  case  about  500  grammes  of 
blood  were  transfused.  His  general  condition  improved, 
and  the  dysentery,  which  had  been  treated  by  Dopter's 
serum,  disappeared  little  by  little.  Twenty-five  days 
after  arrival,  his  temperature  was  normal  and  the  wounds 
rapidly  healing.  Suppuration  had  not  reappeared.  This 
case  is  a  striking  example  of  the  possibility  of  suppress- 
ing  suppuration,  and  of  thus   ameliorating,  to  a   very 


214     TREATMENT   OF    INFECTED   WOUNDS 

real  extent,  the  condition  of  a  patient  who,  treated  by 
the  usual  methods,  would  have  suffered  amputation  and 
probably  have  died. 

The  treatment  of  suppurating  wounds,  accompanied 
or  not  by  fracture,  taken  from  the  convoys  going  to 
Paris,  has  shown  us  that  suppuration  can  be  easily  dried 
up  in  a  few  days.  In  hospitals  in  the  interior  where 
wounded  in  similar  conditions  are  treated,  and  where 
the  method  is  applied  in  all  its  integrity,  similar  results 
have  been  observed. 


II.  Consequences  of  the  Sterilisation  of 

Wounds 

The  suppression  of  suppuration  and  infection  in  the 
majority  of  wounds  has  important  consequences  for  the 
patient,  since  it  diminishes  to  a  very  large  extent  the  local 
and  general  complications  of  wounds,  and  consequently 
the  length  of  treatment  and  the  degree  of  final  incapacity. 

A.  Diminution  of  the  Frequency  and  Intensity  of  General 
Complications. — The  rapid  sterilisation  of  wounds  nearly 
always  protects  patients  from  those  complications  which 
lead  to  death.  From  the  month  of  December,  191 5,  to 
October  i,  19 16,  303  cases  of  wounded  coming  directly 
from  "  postes  de  secours  "  were  treated  at  the  hospital 
for  research  at  Compiegne.  Thirteen  died  after  a  stay 
in  the  hospital  of  more  than  twenty-four  hours.  In 
eight  cases  death  was  due  to  extensive  anatomical 
damage  to  brain,  contents  of  mediastinum,  or  abdominal 
organs.  In  three  cases  it  followed  multiple  wounds  of 
the  two  lower  limbs,  thorax  and  upper  limb.  Twice 
only  was  it  due  to  septicaemia.     One  officer,  who  had  a 


THE   RESULTS  215 

fracture  of  the  thigh  with  great  smashing  up  of  the  bone, 
developed  rapid  gas-producing  septicaemia  which  in 
spite  of  amputation  resulted  in  death.  In  the  second 
case,  staphylococcal  septicaemia  developed  in  the  train  of 
a  fracture  implicating  almost  the  whole  length  of  the 
femoral  diaphysis.  This  case  also  terminated  by  death. 
In  'all  the  other  cases  it  was  possible  to  avert  serious 
general  infection.  It  is  probable  that  the  improvements 
which  experience  has  enabled  us  to  make  in  our  methods 
would  allow  us  to-day  to  obtain  recovery  from  lesions 
similar  to  those  which  determined  the  two  fatal  septi- 
caemias. Lowering  of  the  rate  of  mortality  from  infec- 
tion has  been  observed  by  other  surgeons  who  have 
applied  the  method  in  its  entirety. 

The  general  condition  of  the  cases  whose  wounds  are 
in  a  fair  way  to  become  sterilised  is  habitually  good, 
even  when  the  temperature  is  more  or  less  elevated. 
This  phenomenon  was  exhibited  in  a  striking  manner  by 
those  cases  which  were  brought  to  hospital  with  injuries 
of  long  standing  and  freely  suppurating.  Immediately 
the  suppuration  disappeared  clinically,  the  general  aspect 
of  the  patient  changed.  The  first  effect  of  the  cleansing 
of  wounds  was  always  marked  improvement  in  the  general 
condition. 

B.  Diminutioii  in  the  Number  of  Amputations. — The 
suppression  of  infection  has  permitted  us  to  escape  the 
lymphangitis,  abscesses,  and  purulent  tracks  which  usually 
accompany  infected  fractures  and  joint-injuries.  In  a 
year  we  have  only  seen  three  abscesses.  One  was  the 
result  of  a  lymphangitis  which  existed  before  treatment. 
The  two  others  developed  in  the  neighbourhood  of  a 
fracture  of  the  humerus  and  of  an  infected  knee.     These 


2i6     TREATMENT    OF    INFECTED   WOUNDS 

abscesses  were  opened,  sterilised,  and  closed  in  three  or 
four  days.  In  cases  where  the  extent  and  complexity  of 
the  lesions  do  not  permit  rapid  sterilisation,  the  destruc- 
tion of  the  greater  quantity  of  the  microbes  and  gan- 
grenous tissue  immediately  produced  considerable  local 
amelioration.  From  this  resulted  the  possibility  of  pre- 
serving limbs  which  presented  very  extensive  lesions,  or 
of  performing  conservative  operations  instead  of  carrying 
out  radical  treatment.  In  nearly  every  case  where 
resection  of  the  elbow  or  shoulder  was  indicated,  we 
were  content  with  an  arthrotomy  and  disinfection  of  the 
articulation.  It  was  the  same,  to  a  certain  extent,  with 
the  knee.  In  the  case  of  fractures,  operations  for  the 
removal  of  splinters  have  been  reduced  to  a  minimum, 
and  thus  have  been  avoided  those  cases  of  marked 
shortening  and  the  pseudarthroses  which  are  so  often 
seen  after  large  removal  of  bony  fragments. 

Amputations  have  been  able  to  be  reduced  to  the 
cases  in  which  the  crushing  of  almost  the  whole  of  the 
portion  of  the  skeleton  concerned,  or  the  destruction 
of  the  vasculo-nervous  supply,  rendered  impossible  the 
conservation  of  the  limb.  From  December  i,  1915,  to 
October  I,  1916,  we  have  done  twenty-three  amputations. 
These  amputations  were  necessitated  in  four  cases  by 
crushing-up  of  the  bones,  accompanied  by  section  of 
vascular  trunks.  In  sixteen  cases  it  was  a  matter  of 
limbs  being  partially  or  completely  torn  away  by  shells, 
or  more  especially  bombs.  The  operation  consisted 
in  either  completing  the  amputation  with  scissors,  or  in 
amputating  a  little  higher  up  where  the  bone  became 
normal.  As  a  general  rule,  amputation  was  practised 
directly  through  the  contused  seat  of  fracture,  which  the 


THE    RESULTS  217 

application  of  numerous  instillation  tubes  allowed  to  be 
sterilised  in  a  few  days.  In  only  three  cases  was  amputa- 
tion determined  by  infection.  Two  were  the  cases  of 
septicaemia  of  which  we  have  already  spoken.  The  third 
case  was  a  fracture  of  the  upper  part  of  the  forearm  with 
extensive  vascular  lesions  and  a  considerable  diminution 
of  the  circulation  of  the  limb.  This  case  had  been 
operated  on  previously  in  an  "  ambulance."  After  a  few 
days  the  skin  became  mottled  with  bluish  patches,  at 
the  same  time  signs  of  septicaemia  appeared.  Ampu- 
tation was  done,  and   the    patient   recovered.      Similar 

results  were   observed  in  the  hospital  at  V by  M. 

Ferret,  who,  out  of  one  hundred  cases,  only  amputated 
once.  The  sterilisation  of  wounds,  therefore,  permits  of 
the  preservation  of  nearly  all  limbs  which  are  not 
rendered  useless  by  the  extent  of  destruction  of  osseous, 
vascular,  or  nervous  elements. 

The  possibility  of  disinfecting  injuries  lessens  the 
number  of  amputations  in  a  very  great  proportion,  since 
this  operation  to-day  in  70  per  cent,  of  the  cases  is 
caused  by  septic  sequelae. 

C.  Diminution  of  Length  and  Cost  of  Treatment. — The 
length  of  time  treatment  has  to  be  carried  on  has  been 
lessened  because  wounds  have  been  rapidly  closed,  and 
because  repair  of  bone,  muscle,  and  nerve  has  been 
effected  at  an  early  stage. 

1st.  Influence  of  Secondary  Closure  on  the  Duration  of 
Treatment. — Wounds  of  the  soft  parts,  both  fresh  and 
suppurating,  were  closed  in  the  proportion  of  90  per 
cent,  from  the  fifth  to  the  twentieth  day,  in  whatever 
stage  of  the  wound  the  treatment  may  have  been  com- 
menced.    Wounds  not  sutured  in  this  period  were  also 


2i8     TREATMENT   OF   INFECTED   WOUNDS 

sterilised,  though  in  a  slower  manner.  If  the  wounds 
thus  closed  during  the  first  twenty  days  of  treatment 
had  been  treated  by  the  usual  methods,  they  would  have 
needed  from  one  to  six  months  to  cicatrise.  By  early 
suture  a  diminution  of  about  two-thirds  of  the  duration 
of  treatment  is  obtained. 

In  compound  fractures  of  flat  bones,  short  bones, 
and  long  bones  such  as  the  fibula,  radius,  and  ulna, 
sterilisation  comes  about  as  quickly  as  in  the  wounds  of 
soft  parts.  The  saving  in  the  length  of  time  needed  for 
treatment  was  therefore  very  considerable,  because  these 
compound  fractures,  treated  in  the  ordinary  way,  often 
suppurated  for  several  months.  It  is  well  known  how 
slowly  deep  wounds  of  the  tarsus,  for  example,  recover 
when  they  are  infected.  One  cannot  estimate  exactly 
the  diminution  produced  by  sterilisation  in  injuries  of 
the  humerus,  tibia,  and  femur.  But  this  diminution  is 
considerable.  In  fact,  compound  fractures  of  the 
humerus,  when  sterilised,  are  often  closed  after  the 
lapse  of  from  twelve  to  twenty  days,  when  similar  cases, 
treated  by  the  ordinary  methods,  are  still  suppurating 
after  six,  seven,  or  eight  months.  It  is  also  evident 
that  the  closure  of  compound  fractures  of  the  femur 
after  fifteen,  twenty,  or  twenty-five  days  constitutes  a 
great  advance. 

2nd.  Influence  of  Early  Anatomical  Repairs  on  the 
Duration  of  Treatment. — Sterilisation  of  the  wound  allows 
us  to  practise  operations  quite  early  in  the  case  which 
formerly  had  to  be  put  off  until  after  cicatrisation  was 
complete.  In  this  manner  bone-grafting  or  wiring,  re- 
union of  muscle  or  tendon,  nerve  suture,  before  to-day, 
could  only  be  practised  after  the  healing  of  the  infected 


THE   RESULTS  219 

wound.  This  cicatrisation  often  was  only  obtained  after 
the  lapse  of  several  months.  To-day,  we  set  about  these 
reconstructions  as  soon  as  the  wound  is  sterile,  that  is 
to  say,  from  the  eighth  to  the  fifteenth  day. 

Case  433  presented  a  section  of  all  the  tendons  and 
the  median  nerve  just  above  the  right  wrist.  He  was 
brought  to  the  hospital  three  and  a  half  hours  after  the 
injury.  The  wound  was  immediately  cleansed  and  pro- 
vided with  instillation  tubes.  After  ten  days  it  was 
sterile.  On  the  eleventh  day,  all  the  tendons  and  the 
median  nerve  were  sutured,  and  seven  days  later,  the 
skin  wound  was  closed  without  drainage.  Healing  took 
place  by  first  intention.  This  case  had  at  the  same  time 
an  inter-articular  fracture  of  the  right  elbow,  and  a 
fracture  of  the  left  humerus,  which  were  sutured  at  the 
same  time,  and  likewise  united  by  first  intention. 

Reparation  of  bone  tissue  may  be  made  with  equal 
safety  at  an  early  date.  Case  518,  aged  23,  had  a  fracture  of 
the  vault  of  the  cranium  with  a  large  wound  of  the  hairy 
scalp.  Phenomena  of  compression  disappeared  as  the 
result  of  a  craniectomy,  in  the  course  of  which  a  fragment 
of  bone  the  size  of  a  crown-piece  was  removed.  Four 
days  later,  the  wound  having  become  sterile,  M.  Woimant 
made  good  the  loss  of  bone  substance  by  an  osteo- 
periosteal flap  taken  from  the  internal  surface  of  the 
left  tibia.  The  scalp  was  closed  hermetically,  and  union 
took  place  by  first  intention.  The  case  was  examined 
anew  forty  days  later.  It  was  found  that  the  graft  had 
exactly  adapted  itself  to  the  cranial  wall. 

3rd.  Diminution  of  the  Cost  of  Treatment.  —  The 
expenses  of  treatment  are  considerably  lessened,  since 
its  length  is  so  much  less  than  by  other  methods.     The 


220     TREATMENT   OF    INFECTED   WOUNDS 

saving  thus  realised  is  from  about  50  to  70  per  cent. 
Besides,  the  substances  used  in  the  treatment  are  not 
costly.  The  net  cost  of  Dakin's  solution  is  three  centimes 
the  litre,^  whilst  ether,  alcohol,  peroxide  of  hydrogen  and 
balsam  of  Peru  are  very  much  dearer.  Suppuration  being 
done  away  with,  the  dressings  are  but  slightly  soiled,  and 
almost  the  whole  of  the  gauze  may  be  used  again.  {La 
gaze  pent  etre  presque  entieremeiit  r^cicperee. — Fr.)  The 
cost  of  the  appliances  for  instillation  is  recovered  in  a 
few  days  from  the  saving  due  to  the  exclusive  employ- 
ment of  a  substance  of  such  trifling  cost  as  hypochlorite 
of  soda. 

D.  Diminution  of  Positive  Incapacity. — In  the  greater 
number  of  injuries,  definite  incapacity  is  the  result  of 
infection.  As  the  sterilisation  of  wounds  permits  the 
avoidance  in  many  cases  of  amputations  and  resections, 
there  results  a  considerable  diminution  in  the  amount  of 
pensions  payable  to  the  wounded  men  by  the  State.  It 
is  also  well  known  that  the  presence  of  infection  in  a 
compound  fracture  of  a  leg  or  thigh,  raises  the  positive 
incapacity  rate  from  5  or  10  per  cent,  to  25  or  50  per 
cent,  and  more.  The  gain  from  the  suppression  of 
infection  is  therefore  very  evident.  In  successfully  treat- 
ing fractures  without  extensive  removal  of  bone  substance, 
considerable  shortening  of  limbs  and  pseudarthroses  are 

*  Net  cost  of  ten  litres  of  Dakin's  solution  : — 

200  gr.  chloride  of  lime  at  i  fr.  lo  centimes    .  .  .     0*22 

100  gr.  carbonate  of  soda  (Solway)  at  o  fr.  40  centimes     .     0*04 
800  gr.  bicarbonate  of  soda  at  o  fr.  60  centimes        .         .     0*048 


Net  cost  of  10  litres 0*308 

Therefore  the  net  cost  of  a  litre  is  3  centimes  (roughly,  three  pints 
cost  a  halfpenny). 


THE    RESULTS  221 

frequently  avoided.  Sinuses  are  scarcely  ev^er  seen  in 
cases  thus  treated.  The  recovery  is  all  the  more  com- 
plete, for  a  case  of  compound  fracture  of  the  tibia,  the 
femur  or  the  humerus,  sutured  after  the  lapse  of  a  few 
days  only,  presents  neither  the  muscular  atrophy,  the 
retraction  of  tendons,  nor  the  joint-stiffness,  which,  after 
long  periods  of  suppuration,  reduce  limbs  to  the  verge  of 
impotence. 

Sterilisation  of  wounds  is  equally  successful  in  securing, 
more  readily  than  by  the  other  methods,  healing  of  deep 
wounds  of  the  soft  parts.  In  reality,  since  tendons  and 
muscles  can  be  sutured  as  soon  as  the  wound  is  sterile, 
the  unions  are  stronger.  Nerve  suture  likewise  is  done 
under  excellent  conditions.  In  wounds  of  muscle,  the 
deep  and  painful  cicatrices,  which  so  hamper  the  useful- 
ness of  a  limb,  are  not  produced.  It  is  quite  certain 
that  the  economies  in  the  amount  of  pensions  paid  by 
the  State,  obtained  b}'  means  of  the  sterilisation  of  wounds, 
are  very  considerable. 

III.  Failures  and  Their  Causes 

Failures  teach  more  than  successes.  Therefore  it  is 
important  to  examine  in  what  cases  the  method  fails  to 
sterilise  wounds,  and  what  are  the  causes  of  these 
failures. 

A.  Wounds  of  the  Soft  Parts  not  accompanied  by  Bone 
Injuries. — If  the  surgical  sterilisation  of  a  wound  be 
considered  as  the  object  of  the  method,  it  might  be 
asserted  that  no  failure  has  been  observed  since  the 
month  of  December,  191 5.  But  if  the  role  of  the  method 
is  to  prepare  for  the  secondary  closure  of  wounds,  the 
proportion  of  failures  rises  to  about  five  per  cent. 


222     TREATMENT   OF    INFECTED   WOUNDS 

These  failures  are  due  to  the  following  causes  :  — 

{a)  Errors  in  the  bacteriological  examination.  In 
spite  of  the  absence  of  microbes  from  the  smears,  suture 
of  the  wound  was  followed  by  infection.  This  accident 
was  very  rare  and  always  without  serious  results.  It 
was  met  with  twice  in  the  course  of  333  cases  of  wound- 
closing.  Wounds,  the  seat  of  infection,  were  reopened 
and  sterilised  in  a  few  days.  This  accident  was  the 
consequence  of  specimens  for  the  smears  being  badly 
taken  ;  and  can  be  avoided  by  taking  multiple  specimens, 
especially  from  the  most  obscure  parts  of  the  irregularities 
of  the  wound. 

(b)  Loss  of  tissue-substance.  In  some  cases,  the  loss 
of  integumental  substance  was  very  extensive,  and  union 
impracticable.  In  other  cases,  union  became  possible, 
if  traction  more  or  less  great  by  sutures  were  employed. 
But  these  cut  the  skin  and  union  remained  imperfect. 

{c)  Closure  without  bacteriological  examination.  It 
sometimes  happened  that,  seeing  a  wound  of  good  red 
colour,  without  secretion,  and  with  margins  perfectly 
supple,  the  surgeon  did  not  wait  for  a  laboratoiy  report, 
and  sutured.  Under  these  conditions,  the  operation 
sometimes  resulted  in  failure.  This  mistake  has  not 
been  committed  in  our  hospital  since  the  month  of 
December,  191 5.  Before  that  date,  it  happened  several 
times. 

When  the  treatment  was  commenced  after  a  period 
of  suppuration  more  or  less  long,  numerous  failures  of 
the  method  might  have  been  expected.  Nevertheless, 
all  the  suppurating  wounds  arrived  at  the  stage  of 
surgical  sterilisation,  and  no  failure  was  registered.  The 
closure  of  these  wounds  was  practised  at  a  later  date 


THE    RESULTS  223 

than  when  dealing  with  fresh  wounds,  but  nearly  all  the 
cases  were  sutured. 

B.  Wounds  of  the  Soft  Parts  accompanied  by  Injuries 
to  Bone. — In  compound  fractures,  and  especially  in  those 
which  had  suppurated  before  the  commencement  of 
sterilisation,  we  did  not  always  achieve  surgical  sterilisation. 
From  this  point  of  view,  the  results  of  treatment  of  com- 
pound fractures  can  be  clearly  separated  from  those  of 
wounds  of  the  soft  parts.  Failures  were  more  frequent. 
We  look  upon  as  a  failure  {comme  echec^  Fr.)  the  case  in 
which  some  microbes  persist  in  the  secretions  up  to  the 
moment  of  spontaneous  closure  of  the  seat  of  fracture. 

We  have  observed  no  failure  in  the  treatment  of 
compound  fractures  of  the  small  bones,  short  bones,  and 
radius  and  ulna.  But  some  compound  fractures  of  the 
humerus,  tibia,  and  femur  did  not  respond  completely 
to  treatment.  The  statistics  of  these  cases  will  not  afford 
any  indication  of  interest,  because  the  methods  have 
been  progressively  modified,  and  the  results  are  improving 
more  and  more.  In  the  last  fifteen  cases  of  fracture  of 
the  humerus  which  have  been  under  our  care,  several  of 
which  were  freely  suppurating  at  the  commencement 
of  treatment,  only  four  were  not  sutured.  In  two  cases, 
suture  was  not  practised  because  of  loss  of  substance. 
In  only  two  cases  surgical  sterilisation  of  the  seat  of 
fracture  was  not  attained.  In  one  case  it  was  a  "  smash- 
up"  of  the  end  of  the  diaphysis  and  the  adjoining 
head  of  the  humerus,  and  the  other  case  was  a  highly 
comminuted  fracture  of  the  shaft.  In  both  cases  the 
secretions  contained  some  microbes  up  to  complete 
cicatrisation.  Recovery  took  place  without  a  sinus 
remaining". 


224     TRKATMENT   OF    INFFXTED   WOUNDS 

In  compound  fractures  of  the  tibia,  the  loss  of  sub- 
stance is  often  too  great  to  allow  of  the  soft  tissues  being 
completely  brought  together.  In  similar  fractures  of  the 
femur,  approximation  of  the  tissues  was  always  possible, 
but  microbes  often  remained  in  the  secretions,  and  pre- 
vented suture  being  carried  out.  Of  our  last  six  cases 
of  compound  fracture  of  the  femur,  in  three  we  did 
not  suture,  because  the  secretions  yielded  occasional 
microbes  ;  the  wounds  closed  spontaneously. 

IV.  Practical  Value  of  the  Method 

The  results  observed  at  Compiegne  showed  us  that 
suppuration  of  woitnds  can  be  suppressed.,  and  that  tJie 
majority  of  wounds  are  capable  of  bei?ig  sterilised  and 
sutured.  The  practical  value  of  the  method  depends 
upon  the  possibility  of  its  being  employed  at  other 
hospitals.  The  objection  has  been  raised,  in  fact,  that 
the  chemical  sterilisation  of  wounds  is  too  difficult  to 
become  general  {est  d'une  technique  trop  delicate  pour 
Hre  generalisee).  It  will  be  useful,  therefore,  to  demon- 
strate how,  without  increase  of  staff,  by  the  aid  of  ap- 
paratus whose  cost  does  not  exceed  a  dozen  francs  per 
bed,  using  substances  which  cost  much  less  than  ether, 
hydrogen  peroxide,  or  alcohol,  usually  employed  in 
treatment  of  wounds  ;  the  abortive  treatment  of  infec- 
tion and  the  curative  treatment  of  suppuration  have 
been  applied  in  some  hospitals  at  the  front  {ambulances 
deVavant),  and  in  some  territorial  hospitals  {du  territoire). 

A.  Abortive  Treatment  of  Infection. — The  abortive 
treatment  of  infection,  instituted  at  Compiegne  in  the 
spring  of  191 5,  has  been  carried  out  in  the  "  ambulances" 


THE    RESULTS  225 

from  the  month  of  July  in  the  same  year  by  le  Medecin 
Principal  Ufifoltz,  Directeur  du  Service  de  Sante  d'un 
Corps  d'Armee.  From  that  date  M.  Uffoltz  and  his 
colleagues  have  demonstrated  that  under  the  ordinary 
conditions  of  a  field  hospital  {ambidance,  Fr.),  the  method 
could  be  employed  almost  in  its  entirety,  and  that  a 
considerable  improvement  in  results  was  the  conse- 
quence. In  one"  of  the  "  ambulances  "  under  the  charge 
of  M.  Ufifoltz,  le  Medecin-Major  Ferret  succeeded  in 
banishing  wound  infection  almost  completely.  The 
ordinary  staff  was  able  to  apply  the  method  in  accurate 
detail.  The  demonstration  of  the  practical  value  of  the 
method  in  the  "  ambulances "  (field  hospitals)  was 
brilliantly  achieved  by  MM.  Hornus  and  Perrin,  who 
succeeded  in  protecting  their  cases  from  septic  "  acci- 
dents," in  preserving  limbs  with  enormous  injuries,  and 
in  cutting  short  to  a  large  extent  the  duration  of  treat- 
ment, by  the  secondary  union  of  wounds. 

Nor  is  the  number  of  cases  any  obstacle  to  the  em- 
ployment of  the  method.  At  "  I'ambulance  de  La 
Panne,"  which  contains  from  600  to  700  wounded,  M. 
Depage  and  his  colleagues  have  shown  that  the  sterilisa- 
tion of  wounds  can  be  carried  out  on  a  large  scale.  It 
has  been  said,  in  fact,  that  the  small  size  of  our  hospital 
at  Compiegne  allows  us  to  lavish  an  amount  of  attention 
on  our  cases  which  would  be  impossible  if  these  cases 
amounted  to  several  hundreds.  Therefore  it  is  important 
to  realise  that  in  a  great  hospital  they  have  succeeded 
in  practising  the  sterilisation  of  wounds  in  every  case,  in 
following  the  progress  of  chemical  cleansing  upon  the 
bacteriological  charts,  and  in  closing  wounds  as  soon  as 
they  ceased  to  harbour  microbes.     In  this  hospital,  which 

15 


226     TREATMENT   OF    INFECTED   WOUNDS 

contains  nearly  700  wounded,  they  have  succeeded  in 
almost  completely  doing  away  with  suppuration,  with- 
out having  to  add  to  the  personnel  or  to  alter  the  general 
organisation. 

The  results  observed  in  M.  Uffoltz'  "  ambulances  " 
and  M.  Depage's  hospital,  show  that  the  abortive  treat- 
ment of  infection  can  be  realised  in  the  "  formations 
sanitaires "  at  the  front,  when  these  are  well  organised 
and  controlled. 

B.  The  Disinfection  of  Suppurating  Wounds.—  The  ap- 
plication of  the  method  in  the  territorial  hospitals  where 
suppurating  wounded  are  received,  days  or  weeks  after 
the  injury,  has  not  yet  been  tried  on  a  large  scale.  In 
these  hospitals  wounds  suppurate  for  a  prolonged  period 
in  spite  of  all  the  forms  of  treatment  employed  hitherto. 
However,  the  method  has  been  applied  in  its  entirety 
by  some  surgeons.  Immediately,  suppuration  has  practi- 
cally disappeared  from  their  clinics.  In  this  manner  in 
M.  Tuffier's  hospital  at  Saint -Germain,  and  in  M. 
Chutro's  wards  at  the  Buffon  hospital,  it  became  possible 
to  do  away  with  suppuration  in  wounds  without  adding 
to  the  number  of  doctors  and  nurses. 


V.  Conclusions 

Since  our  methods  have  been  employed  with  success 
under  the  ordinary  conditions  of  "ambulances"  and 
hospitals,  the  sterilisation  of  both  fresh  and  suppurating 
wounds  ought  to  be  practised  almost  everywhere.  But 
surgeons  should  not  forget  that  all  the  details  of  the 
method  have  been  studied  experimentally  and  estab- 
lished  in    a   certain    way   to   produce   a   certain  result. 


THE   RESULTS  227 

Neither  the  preparation  of  Dakin's  solution  may  be 
modified,  nor  the  processes  for  mechanical  and  chemical 
cleansing  of  wounds.  It  is  indispensable  to  learn  the 
method  before  attempting  to  apply  it,  and  this  appren- 
ticeship demands  several  weeks,  even  from  an  experienced 
surgeon.  But  we  can  be  quite  sure  that,  applied  in  their 
entirety,  the  methods  just  described  will  produce  the 
desired  results.  Admitted,  their  use  exacts  more  pre- 
cision and  more  care  than  the  old  methods,  for  any 
approach  towards  technical  perfection  requires  more 
elaborate  apparatus  and  a  more  specialised  staff.  But 
efforts  of  no  great  magnitude  on  the  part  of  doctors 
and  nurses  will  most  certainly  yield  an  immense  improve- 
ment in  results. 

The  nation  has  the  right  to  ask  from  the  medical 
corps  that  progress  in  the  treatment  of  the  wounded 
which  is  so  acutely  needed. 


APPENDIX 


CHLORAMINE    PASTE 

The  formula  for  chloramine  paste  is  not  given  in  the  French 
edition.     M.  Carrel  informs  me  it  is  made  as  follows  : — 

"  Chloramine  T  .  .  .  lo 
Stearate  of  Soda  .  .  .  70 
Water 1000 

The  preparation  of  this  substance  is  somewhat  difficult,  and  it 
should  be  made  by  means  of  a  mechanical  mixer,  in  order  to 
obtain  a  thoroughly  homogeneous  paste." 

HERBERT   CHILD. 


22S 


INDEX 


{^Names  m  italics. 


Abortive   treatment  of  infection, 

224 
Abscess,  215 

,  cavity,  closure  of,  41 

J  ?  results,  193 

,  gas,  105 

,  lymph angi tic,  105 

,  opening,  109 


Absence  of  scientific  method,  35 
x'Vbsorbent  gauze,  62 
Acetic  acid,  78,  81 
Activity,  coefficient  of,  82 
Adhesive  plaster,  181.     See  Strap- 
ping 

,  with  hooks,  183 

Adversaries  of  antisepsis,  4 
Algebraic    expression   of   curve    of 

cicatrisation,  37,  149 
Alkali,  free,  effect  on  vessels,  7^ 
, ,  in  antiseptic  solutions, 

73 
Alkalinity  of  hypochlorite,  29 
American  methods,  M.  Br  oca  on,  10 

,  of  traction,  183 

,    suspension    apparatus, 

149 
Amino-acids,  47 
Ampoule,  116 
Amputations,   lessened  number  of, 

215 


Amputations,  due  to  sepsis,  2 
Anaesthesia,  93 
Anatomical  repairs,  early,  218 
Antisepsis,  adversaries  of,  4 
Antiseptics,  action  of,  on  tissues,  19 

,  application  of,  62 

,  choice  of,  14 

,    contact     of,    with    micro-or- 
ganisms, 53 

,  duration  of  application  of,  67 

,  fatty  vehicles  for,  24 

,  free  alkali  in,  73 

,  in  powder  form,  24 

,  instillation  of,  139 

,  maintaining  strength  of,  65 

,  preparation  of  wound  for,  60 

Apparatus,  irrigating,  Il6 

,  suspension,  American,  149 

Appearance  of  patients,  152 
Appendicitis,  illustrations  from,  90, 

91 
Area  of  wounds,  measurement  of,  36 
Arrangement  of  tubes,  131 
Arthritis,  suppurative,  iio 
Asepsis,  bacteriological,  177 

,  surgical,  177 

V.  antisepsis,  5 


x\septic    wound,    action    of 

chlorite  on,  44 
Audioscope  vibrator,  97  • 


hypo- 


229 


230 


INDEX 


Bacillus  of  IVekhy  i6,  i8,  167 

aerogenes  capsulatus,  18 

perfringens,  18,  31 

pyocyaneus,  16,  24 

Bactericidal  action  of  chlorine,  47 

of  Dakin's  solution,  24 

of  para- toluene -sodium - 

sulphochloramine,  50 
Bacteriological  asepsis,  177 

conditions,  7 1 

,  modifications  of,  161 

examination,  155 

,  closure  without,  222 

,  errors  in,  222 

,  necessity  for,  154 

study  of  secretions,  14 

Bath-towelling,  114 
Baunie-Pluvinel,  M.  de,  97 
Beaujon  Hospital,  19 
Beck's  paste,  185,  194-5 
Benzene -sodium-sulphochloramine, 
49 

bactericidal  action  of,  50 

Bergonie,  A/.,  electro-vibrator,  97 
Berthollet,  M.,  73 
Bicarbonate  of  soda,  75,  80 
Bichloride  of  mercury,  17,  18,  20 
Blood,  chemio-therapy  of,  13 
Blue  pus,  207-8 
Bone,  conservation  of,  197 

grafting,  ill,  219 

Boot-lace  hooks,  183 
Boric  acid,  22,  24,  86 

,  irritation  from,  75 

Bradford's  frame,  138,  149 
Broca^  J/.,  on  American  methods, 

10 
Bromamines,  51 
Bromine,    bactericidal    power    of, 

47 
Buffon  hospital,  226 
Burghard,  M.,  4 
Buttock,  wound  of,  189 


Calcium,  chloride  of,  76,  85 

,  hypochlorite,  23,  76,  85 

Calculated  curves  of  cicatrisation, 

38 
Calf,  haematoma  of,  19 1 
Cannulae,  glass,  117 

,  fixation  of,  136 

Carbol  thionin,  158 
Carbolic  acid,  17,  20 
Carbonate  of  lime,  76 

of  soda,  75,  85 

,  Solway,  79 

,  hydrated,  79 

Carrel,  Mine.,  1 9 
Catgut  ligatures,  108 

chromic,  108 

Causes  of  death,  214 

of  error,  solution,  86 

,  smears,  160 

of  failure,  221 


Caustic  soda,  80,  86 
Cavities,  abscess,  41,  193 
Cells,  mononuclear,  172 

,  polynuclear,  172 

Changing  dressings,  138 

Charts,  numbers  of  microbes,  26,  28 

Chaltaii^ay,  AT.,  49 

Chemical  cleansing  of  wounds,  109 

equations,  80 

sterilisation,  iii,  112 

Chemio-therapy,  7 

of  blood,  13 

of  wounds,  13 

Chloramine  paste,  127,  228 

T.,  52 

Chloramines,  7,  47,  49 

,  wounds  treated  by,  72 

Chloride  of  lime,  75 

,  chemical  constitution  of, 

76 

,  titration  of,  76 

,  variations  in,  77 

Chlorine,  24 


INDEX 


231 


Chlorine,  bactericidal  powers  of,  47 

,  estimation  of,  78 

,  gaseous,  76 

Chloroform,  93 
Choice  of  an  antiseptic,  14 
Chromic  catgut,  108 
ChutrOt  M.,  226 
Cicatrices,  painful,  221 
Cicatricial  stage  of  wounds,  1 1 1 
Cicatrisation,  action  of  hypochlorite 
on,  38 

,  curves  of,  38 

,  factors  of,  34 

,  graphic  representation  of,  37 

,  influence  of  sterilisation  on, 

38 

,  DakhCs  solution  on,  43 

Cicatrix,  examination  of  old,  59 
Circulation,  hypochlorites  in,  32 
Cleaning-up    compound    fractures, 
99 

wounds  of  joints,  100 

Cleansing  of  wounds,  chemical,  109 

,  mechanical,  89,  91 

,  surgical,  no 

Clinical  examination,  92,  147 

observation,  71 

,  value  of,  153 

signs,  179 

,  value  of,  1 76 

Closure  of  abscess  cavities,  41 

of  wounds,  178 

,  by  elastic  traction,  182 

,  by  strapping,  18 1 

,  by  suture,  184 

,  fresh,  185 

,  primary,  179 

,  premature,  99 

,  secondary,  217 

,  technique  of,  181 

,  without    bacteriological 

examination,  222 
Clothing,  bhreds  of,  95,  97 


Coefficient  of  activity,  82 

Cohen,  M.,  50 

Compass,  Contremotilin''s^  97 

,  Hirtz\  97 

Compiegne,  hospital  at,  10,  224 
Complications,  diminution  of,  214 
Compound  fractures,    cleaning-up, 

99 

J  closure  of,  184 

,  results,  193 

Condition,    general,    modifications 

of,  151 
of  wounds,  3<^ 


Conducting  tubes,  112 
Conical  glass  tubes,  116 
Connective  tissue,  experiments  on, 

19 

Consequences  of  sterilisation,  214 

Contact   of  antiseptic    and    micro- 
organism, 53,  67 
Continuous  instillation,  139 
Contret7ioulin''s  compass,  97 
Controls,  in  experiments,  35,  42 
Cost  of  Dakin^s  solution,  220 

treatment,  219 

• ,  lessened,  217,  220 

Coton  carde,  135 
Cotton  wick,  62,  123 

wool,  134 

Counter-openings,  97,  98 
Counting  microbes,  158,  174 
Crins  de  Florence,  200 
Culture  experiments,  16 
Cultures,  155,  178 
Cup-like  wounds,  124 
Curves   of    cicatrisation,    algebraic 
formula,  37,  149 

,  calculated,  38 

,  geometrical  form  of,  37 

,  observed,  38 

Cutaneous    origin    of    reinfection, 

165 

Cytophylaclic  substances,  173 


232 


INDEX 


Dakin's  investigations,  6,  15 

solution,  20,  24 

-,  action  on  blood,  33 

, on  pus,  33 

,   on  leucocytes,  33 

■ ,    bactericidal   action   of, 

24 

,  cost  of,  220 

,  influence    on    cicatrisa- 
tion, 43 

,  preparation  of,  73,  75 

,  strength  of,  88 

,  technique,  73 

,  to  be  coloured,   139 

,  toxicity  of,  32 

,  wrongly  made,  86 


Dasire,  M.,  29 

Daufresne^  M.,  15,  22,  24,  50 

method,  75 

Deep  sutures,  176 

Dehelly,  M.,  9 

Delbei,  M.  Pierre,  5 

Depage,     M.,     10,     61,     95,     201, 

225-6 
Dimensions  of  wounds,  69 
Diminution  in  cost,  217,  220 

of  complications,  214 

of  incapacity,  220 

Dopter's  serum,  213 
Drainage,  98 
Dressings,  133 

,  changing,  138 

,  four-layer,  134 

,  with  saline   solution,  hyper- 
tonic, 29 

, ,  physiological, 

28 

, vaselin,  27,  43 

Drop-by-drop  instillation,  127 
Drop-counter,  120 
Dunham  f  Prof.  E.  K.,  18 
Dunkirk,  hospital  at,  24 
Duptty,  M.,  9 


Duration   of    application   of    anti- 
septic, 67 
Duration  of  instillation,  141 
Duyk,  M.,  21 

Eau  de  Javel,  20,  22,  23 

,  commercial,  84 

Elastic  traction,  wound-closing  by, 

182 
Elbow,  shell-wound,  203 
Elevator,  periosteal,  no 
Electro-vibrator,  Bergonie's,  97 
Encapsuled  microbes,  176 
Eponge,  tissu,  114 
Equations,  chemical,  80 
Errors,  causes  of,  86 
, ,  in  bacteriological  exami- 
nation, 222 
,  ,   in  counting  microbes, 

174 

, ,  in  smears,  159,  160 

, ,  in  solution,  86 

, ,  of  technique,  142 

Ether,  93 

Examination,  bacteriological,  155 

,  ,  closure  without,  222 

, ,  errors  in,  222 

,  clinical,  92,  147 

,  radiological,  92 


Excessive  pressure,  146 

quantity  of  liquid,  144 

Excision  of  track  of  missile,  95 
Experiments,  controls  in,  35,  42 

,  cultures,  16 

,  filter-paper,  26,  30,  42 

,  on  connective  tissue,  19 

,  on  skin,  22 

Fabrics,  waterproof,  135 
Factors  of  cicatrisation,  34 
Failure,  causes  of,  221 

,  definition  of,  223 

Fatty  vehicles  for  antiseptics,  24 


INDEX 


233 


Femur,   fractures   of,    198,    200-1, 

206,  208,  210,  212 
Fiessinger,  M.,  47,  55,  107 
Filter-paper   experiments,   26,    30, 

42 
Fixation  of  cannulae,  136 
— —  of  tubes,  127 
Flask,  for  irrigation,  116 
Forearm,    wounds    of,    190,    207, 

219 
Foreign  bodies,  4I,  69,  171 
Formula  of  curve,  algebraic,  149 
Fractures,  compound,  cleaning-up, 

99 

, ,  closure  of,  184 

,  ,  infected,  106 

,  ,  of  femur,    198,    200-1, 

206,  208,  210,  212 

,  ,  suppurating,  results,  206 

, ■,  with  joint-wounds,  202 

Frame,  Bradford's^  138,  149 
Free  alkali,  effect  on  vessels,  108 
Fresh  wounds,  smears  in,  160 
■,  sterilisation  of,  189 

Gangrene,  gas,  102 

,  localised,  104 

Gangrenous  infections,  loi 

-wounds,  150,  190 

Gas  abscess,  105 
Gas-gangrene,  102 
Gas-producing  infection,  102 

septicaemia,  179 

Gaultier^  M.,  ']2 
Gauze,  absorbent,  62 

,  vaselined,  133 

,  wicks,  68 

Geometrical  form  of  curves,  37 
Glass  tubes,  115,  116 
Grafting,  bone,  ill,  219 
Graphs,  37 

Graphic  representation  of  cicatrisa- 
tion, 37 


Guillaumin^  M.,  48 
Guilloty  M.,  177 

Haematoma,  calf,  191 

,  sciatic  nerve,  99. 

Haematomata,  99 
Haemorrhage,  primary,  108 

,  secondary,  107 

Haemostasis,  96 
Ilirtz'  compass,  97 
Hooks,  on  strapping,  183 
ffornus,  M.f  9,  200,  201,  203,  225 
Horse-serum,  24 
Hospital,  Beaujon,  19 

,  Buffon,  226 

,  Compiegne,  10,  224 

•,  Dunkirk,  24 

,  Saint-Germain,  226 

Humerus,  fractures  of,  194,  207 
Hydrochloric  acid,  78 
Hydrogen  peroxide,  17,  18,  220 
Hypertonic  saline  solution,  29,  62 
Hypobromites,  47 
Hypochlorite  of  soda,  7,  17,  19,  20 

,     action     on     aseptic 

wounds,  44 
, on  cicatrisation,  38, 

44 
, on  microbial  toxins, 

30 

, on  proteins,  25 

,  on  pus,  25 

,  on  silk,  107 

.^  on  tissues,  32,  33 

,  alkalinity  of,  29 

,  in  the  circulation,  32 

,  irritating  qualities  of,  20 

,  mode  of  action  of,  46 

,  retarding  action  of,  44 

,  titration  of,  81 

-,  toxicity  of,  32 


Hypochlorous  acid,  24 
Hypoiodites,  47 


234 


INDEX 


Immobilisation  of  the  limb,  138 
Incapacity,  diminution  of,  220 
Incisions,  long,  99 
Infected  fractures,  106 

wounds,  action  of  hypochlorite 

of  soda  on,  38 

•,  stages  of,  89 

Infection,  abortive  treatment  of,  224 

,  fresh  wounds,  54 

,  gangrenous,  loi 

,  gas-producing,  102 

,  suppurating  wounds,  57 

,  topography  of,  53 

Inflammatory  period,  loi 
Instillation,  continuous,  139 

,  drop-by-drop,  127 

,  duration  of,  141 

,  intermittent,  139 

,  of  antiseptic,  139 

,  pressure  used,  140 

,  quantity  used,  140 

,  time  of,  140 

,  tubes,  112 

Insufficient   penetration   of    liquid, 

142 
Investigation,     team-work    needed 

for,  2 
Iodide  of  potassium,  78,  81 
Iodine,  17,  19,  20 

,  bactericidal  power  of,  47 

,  estimation  of,  81 

,  tincture  of,  94 

Irrigation  apparatus,  1 16 

,  continuous,  66 

,  bottle  for,  116 

Irritation  of  skin,  145,  148 

from  boric  acid,  75 

Isotonic,  76 

Jacomd,  M.,  24 
Joint-injuries,  cleaning-up,  100 

,  closure  of,  184 

,  suppurating,  107 


Joint,  wounds  of,  202 

,  with  fractures,  202 

Junctions  of  tubes,  115 

Keeping  qualities  of  hypochlorite 

solution,  75,  83 
Kenyon,  M.,  50 
Knee-joint,   wounds   of,    190,    204, 

205 

Labarraqiie^  M.,  73 

Lab ar rogue's  liquor,  20,  22,  23,  73» 

84 
Label  on  slides,  158 
Landry^  J/.,  24 
Leishman,  M.^  4 
Lemaire,  M.^  9 

Length   of    time   needed    for   anti- 
septic, 68 

of  treatment,  217 

Leucocytes,  characters  of,  1 72 

,  dissolution  of,  33,  47 

Ligatures,  catgut,  108 

,  silk,  107 

Limb,  immobilisation  of,  138 
Lime,  carbonate  of,  76 

,  chloride  of,  75 

Liquid,  insufficient  penetration  of, 
142 

,  retention  of,  129 

Lister's  ideas,  3 
Lorram-Smith^  M.,  24 
Louis  XVIIL,  corpse  of,  73 
Lumiere,  M.  Auguste,  24,  30 
Lymphangitis,  89,  149 

Magnesium  hypochlorite,  23 
Measurements,  in  investigation,  3 

,  of  wounds,  34 

,  ,  technique  of,  36 

Mechanical   cleansing   of    wounds, 

89,  91 
Medullary  canal,  100 


INDEX 


235 


Membranes,  rubber,  64 
Mercury,  bichloride  of,  17,  18,  20 
Method,  practical  value  of,  224 
Methods,  American,  183 

,  M.  Broca  and,  10 

,  scientific,  absence  of,  35 

Microbes,  charts  of,  26 

,    contact   of    antiseptic   with, 

53.67 

,  counting,  158,  174 

,  encapsuled,  176 

,  rate  of  growth  of,  56 

Moniaz,  yJ/.,  55 

Missile,  excision  of  track  of,  95 
Mononuclear  cells,  172 
Mo  Seng's  mass,  185 
Moyiiihaii,  Sir  B.  G.  A.,  4 
Moyroudy  M.,  9 
Multiple  wounds,  191-2 
Muscle,  suture  of,  184 

Naphthalene  derivatives,  51 
Nerve  suture,  iii,  184,  221 
Nitrate  of  silver,  1 7 
Nouy^  Lecomte  de,  M.^  37,  149 
Nurses,  duties  of,  133,  145 

Odour  of  wounds,  144 
Oleate  of  soda,  neutral,  36,  98 
Opening-up  of  wounds,  94 
Osteitis,  171,  209 
Osteo-myelitis,  91 

Painful  cicatrices,  221 

Panne,   ambulance  de  la,   10,   201, 

225 
Para-toluene-sulphochlorate,  52 
Para  -  toluene  -  sodium  -  sulphochlor- 
amine,  49 
-,  bactericidal  action  of,  50 


Patients,  appearance  of,  152 
Penetration  of  liquid,   insufficient, 

142 
Perforations  in  rubber  tubes,  113 
Perimeter  of  wounds,  35 
Periosteal  elevator,  no 
Peroxide  of  hydrogen,  17,  18,  220 
Ferret,  M.,  9,  225 
Ferj-in,  M.,  196,  200,  203,  225 
Phagocytosis,  33,  173 
Fhelip,  M.,  SS 
Phenol  phtalein  test,  85 
Phlegmonous  infections,  loi 

wounds,  90,  150,  190 

Physiological    saline    solution,    28, 

46,  139 

**  Pickling  "  in  tanneries,  48 
Pince  de  Mohr,  117  ;  avis,  120 
Pinchcock,  spring,  117 

,  use  of,  140 

,  screw,  120 


Planimeter,  use  of,  36 
Plaster,   adhesive,  for  fixing  lubes, 
127 

,  ,  for  wound  closure,  181 

Folicard,  M.,  55,  59,  177 
Polynuclear  cells,  172 
Potassium  hypochlorite,  23 

iodide,  78,  81 

Powder,  antiseptics  in,  24 
Fozzi,  M.,  8,  9,  10,  177 
Pre-inflammatory  stage,  89,  91 
Premature  closure  of  wounds,  99 
Preparation  of  slides,  157 

of  wound,  60 

Pressure,  excessive,  146 
Primary  closure  of  wounds,  179 

haemorrhage,  108 

Projectiles,  search  for,  96 
,  excision  of  track  of,  95 


V&^i^,  Beck's^  185,  194-5 
chloramine,  127,  228 


Proteins,  51 

,  action  of  hypochlorite  on,  25 

Patella,  fracture  of,  204-5  I  »  o^  P"^»  ^5 


236 


INDEX 


Pseudarthroses,  2i6 

Pus,  action  of  hypochlorite  on,  25 

,  blue,  207-8 

,  microbes  of,  168 

,  pockets  of,  170 

,  proteins  of,  25 

Pyrexia,  176 

,  persistence  of,  152 

Quantity  of  liquid,  excessive,  144 

,  instilled,  140 

Quenu,  M.,  9 

Radiological  examination,  92 
Rasrhig^  yl/.,  46 

Reinfection,    cutaneous    origin    of, 
165 

,  from  pockets  of  pus,  1 70 

Repair,  speed  of,  38 
Representation,  graphic,  of  cicatri- 
sation, 37 
Resection  of  damaged  tissues,  6 1 

of  joints,  loi 

limited,  100 

of  wounds,  95 

Results,  abscess  cavities,  193 

-y  compound  fractures,  193 

,  of  sterilisation  of  wounds,  188 

Retarding  action   of  hypochlorite, 

44 

Ringer's  solution,  41 
Rubber  membranes,  64 

tubes,  perforated,  63,  113 

Rugine  tranchante,  no 

Saccharine,  by  products,  52 
Safety-pins,  use  of,  137 
Saint-Germain  hospital,  226 
Salicylic  acid,  17 
Saline  solution,  hypertonic,  29, 62 
,    physiological,    28,    46, 

139 
Salts  of  Soda,  79 


Sciatic  nerve,  haematoma  of,  99 
Secondary  closure  of  wounds,  2 1 7 

haemorrhage,  107 

Secretions  of  wounds,  150 

,  changes  in,  144,  151 

,  examination  of,  156 

Septicaemia,  gas-producing,  179 

,  streptococcal,  179 

Sequestra,  209 
Serum,  Dopter's^  213 

,  horse,  24 

Seton  type  of  wounds,  93,  94,  127 

Shape  of  wounds,  124 

Silk,  effect  of  hypochlorite  on,  107 

Silkworm  gut,  200 

Sinus,  effect  of,  164 

Skin,  effect  of  soda  on,  48 

experiments  in  vitroy  22 

irritation  of,  145,  148 

,  from  boric  acid,  75 

reinfection  from,  165 

■  scrapings  from,  167 

sterilisation  of,  94 

Slides,  microscope,  label  on,  158 

— , ,  preparation  of,  157 

, ,  staining  of,  158 

Smears,  technique  of,  156 

,  from  fresh  wounds,  160 

,  causes  of  error,  159,  160 

Soda,  bicarbonate,  75,  80 

,  carbonate,  75,  85 

,  caustic,  80,  86 

,  effect  on  skin,  48 

,  hydrated,  79 

,  salts  of,  79 

,  Solway^  79 

Sodium  chloride  solution,  30 
Solway^  carbonate  of  soda,  79 
Splinters,  bone,  removal  of,  100 
Stagnation  of  liquid,  129 
Staphylococci,  16,  31 
Sleiilisation  of   wounds,  chemical, 
III,  112 


INDEX 


237 


Sterilisation     of     wounds,     conse- 
quences of,  214 

,  fresh,  189 

,  mechanical  cleansing,  89 

Stirrup-piece,  183 

Strapping,  boot-lace  hooks  on,  183 

for  wound-closure,  18  r 

Strength  of  solution,  65 

Streptococci,  16,  31 

Stump,  retraction  of  skin,  183 

trimming,  ill 

Suppression  of  wound-infection,  2, 

219 
Surgical  asepsis,  177 

cleaning,  1 10 

Suppurating    compound    fractures, 
results,  206 

wounds,  57,  108,  132 

,  changes  in,  151 

,  disinfection  of,  226 

,  microbes  of,  168 

■  ,  results,  193 

Suppuration,  suppression  of,  214 
Suppurative  arthritis,  1 1  o 
Suture,  closure  by,  184 

deep,  176 

of  tendon,  184 

Syringe,  Gentile's,  119 

Tables,  17,  77,  79,  83 
Team-work  needed  in  investigation, 

2 
Technique,  errors  of,  142 

of  closure,  181 

of    manufacture    of    Dakiri's 

solution,  73 

of  smears,  156 

principles  of,  13 

Temperature,  importance  of,  176 
Test,  phenol  phtalein,  85 

for  working  of  tubes,  132 

Tetanus,  experiments,  30 

Thigh,  wounds  of,  189.    &,?  Femur 


Thionin,  carbol,  158 

Tibia,  compound  fractures  of,  195, 

197,  198,  211,  224 
Tissot^  yJ/.,  29 
Tissu  eponge,  114 
Tissues,  action  of  hypochlorite  on, 

32,  33 

Titration  of  chloride  of  lime,  76 

of  hypochlorite,  81 

Topical  applications  to  wounds,  34 
Topography  of  infection,  53 
Toxicity  of  hypochlorite,  32 
Tracings  of  wounds,  44 
Traction,  elastic,  wound-closing  by, 
192 

, ,  on  stump,  183 

Treatment,  cost  of,  217,  219 
Trochanters,  fracture  through,  208 
Tubes,  adhesive  plaster  for,  127 

,  arrangement  of,  123,  131 

,  conducting,  112 

,  fixation  of,  127 

,  instillation,  112 

,  perforations  in,  63,  113 

Tuffier,  M.,  i,  8,  9,  10,  19,  226 

Uffoltz,  M.,  8,  9,  225,  226 
Unions,  glass-tube,  115 
Urea,  51 

Vaselin,  dressing,  27,  43 

,  gauze,  133 

Vehicle,  fatty,  for  antiseptics,  24 
Vessels,  effect  of  free  alkali  on,  loS 

,  injury  to,  33,  96 

Vibrator,  audioscope,  97 
Vieiine,  M.,  48 
Vigne,  M.,  9 
Vincent^  M.,  24,  177 
Volume  of  deep  wounds,  37 

Waterproof  fabrics,  135 
sheet,  138 


238 


INDEX 


Welch,  bacilli  of,  i6,  i8,  167 
Wick,  cotton,  62,  123 

,  gauze,  68 

Wowiant,  M.,  177 

Wounds,  action  of  hypochlorite  on, 

26,  38 

■ -,  cicatricial  stage  of.  III 

,  chemio-therapy  of,  13 

,  chemical  cleansing  of,  109 

,  clinical  examination  of,  147 

,  condition  of,  35 

,    closure    of,    178,    217.      See 

Closure  of  Wounds 

^,  cup-like,  124 

,  dimensions  of,  and  time  re- 
quired, 69 

,    foreign    bodies    in,    41,    69, 

171 

,  gangrenous,  150,  190 

,  large,  129 


Wounds,  perimeter  of,  35 

phlegmonous,  90,  150,  190 
primary  union  of,  179 
secondary  union  of,  217 
seton  type  of,  93,  94,  127 
resection  of,  95 
shape  of,  124 
strapping  for,  181 
suppurating,  57,  108,  132 

,  changes  in,  151 

,  disinfection  of,  226 

,  microbes  of,  168 

,  results,  193 

treated  by  chloramines,  72 
volume  of  deep,  37  ^ 

with  several  openings,  129 
with  two  openings,  128 


Wright,  Sir  Almroth,  5,  53,  62 
Y-SHAPED  tubes,  glass,  1 1 5 


BnilHire,  Tifidall  cr  Cox,  8,  Henrietta  Street^  C<n>tnt  Garden^  W.  C. 


MEDICAL  MONOGRAPHS 

Published  by 
PAUL  B.   HOEBER 

67-69  East  59th  St.,  New  York 

This  catalogue  comprises  only  our  own  publications.  It  will 
be  noticed  that  particular  care  has  been  exercised  in  the  selec- 
tion of  Monographs  of  timely  interest. 

We  are  always  glad  to  consider  the  publication  of  new  and 
original  medical  worTcs.  Correspondence  with  Authors  is 
invited. 

ADAM:     Asthma  and  Its  Eadical  Treatment.     By  James 
Adam,    m.a,,    m.d.,    f.e.c.p.s.     Hamilton.     Dispensary   Aural 
Surgeon,  Glasgow  Eoyal  Infirmary. 
8vo,  Cloth,  viii+184  Pages,  Illustrated $1.50  net. 

ADDER:  Primary  IvIalignant  Growths  of  the  Dungs  and 
Bronchi.  By  I.  Adler,  a.m.,  m.d.,  Prof.  Emeritus  New  York 
Polyclinic,  Consulting  Physician,  German,  Beth-Israel,  Har 
Moriah,  People's  and  Montefiore  Hospitals.  8vo,  Cloth,  xdi-j- 
325  Pages,  1  Colored  and  16  Halftone  Plates $2.50  net. 

AMERICAN     JOURNAD     OF     ROENTGENODOGY,     THE. 
Official    Organ    of    the    American    Roentgen    Ray    Society. 
Edited  by  James  T.  Case,  m.d.,  Battle  Creek,  Mich. 
Published  monthly.     (Volimie  TV,  No.  1.    Published  January, 
1917) $5.00  per  year. 

ANNALS  OF  MEDICAL  HISTORY.  Edited  by  Francis  R. 
Packard,  m.d.  Associate  Editors:  Drs.  Harvey  Gushing, 
George  Dock,  Mortimer  Frank,  Fielding  H,  Garrison,  Abra- 
ham Jacobi,  Howard  A.  Kelly,  Arnold  C.  Klebs,  Sir  "William 
Osier,  William  Pepper,  Dewis  S.  Pilcher,  David  Riesman  and 
Edward  C.  Streeter. 

Published  quarterly $6.00  per  year. 

1 


2  HOEBEB'S  MEDICAL  MONOGBAPHS 

AEMSTEONG:     I.  K.  Therapy,  with  Special  Reference  to 
Tuberculosis.     By  W.  E,  M.  Armstrong,  m.a.,  m.d.  Dubliiu 
Bacteriologist  to  Cent.  Lond.  Ophthalmic  Hosp.,  Late  Asst. 
in  Inoculation  Dept.,  St.  Mary's  Hosp.,  Padding,  W. 
8vo,  Cloth,  x-f93  Pages,  Illustrated $1.50  net. 

BACH:     Ultra- Violet  Light  by  Means  of  the  Alpine  Sun 
Lamp,    By  Hugo  Bach,  m.d.,  Bad  Elster,  Germany.    Author- 
ized Transl.  from  German. 
12mo,  Cloth,  114  Pages,  Illustrated $1.00  net, 

BAEEINGER,  JANEWAY  AND  FAILLA:  Eadium  Therapy 
IX  Cancer  at  the  Memorial  Hospital,  (See  Janeway,  Bar- 
ringer  and  Failla.) 

BIGG:  Indigestion,  Constipation  and  Liver  Disorder.  By 
G.  Sherman  Bigg,  Fellow  of  the  Royal  College  of  Surgeons; 
Fellow  of  the  Royal  Institute  of  Public  Health;  Late  Surgeon 
Captain,  Army  Medical  Staff;  Surgeon  AUahabad,  India, 
12mo,  Cloth,  viii+168  Pages $1.50  net. 

BRAUN  AND  FRIESNER:  Cerebellar  Abscess:  Its  Eti- 
ology, Pathology,  Diagnosis  &  Treatment.  (See  Friesner  & 
Braun.) 

BROCKBANK:  The  Diagnosis  and  Treatment  of  Heart 
Disease.  Practical  Points  for  Students  and  Practitioners. 
By  E.  M.  Brockbank,  m.d.  (Vict.),  f.r.c.p.,  Hon.  Phys.  Royal 
Infirmary,  Manchester,  Clin.  Lecturer  Diseases  of  the  Heart, 
Dean  of  Clin.  Instruction,  University  of  Manchester. 
12mo,  Cloth,  2nd  Edition,  120  Pages,  Illustrated.  .$1.50  net. 

BROWNE:  Reliqio  Medici,  Letters  to  a  Friend,  etc.,  and 
Christian  Morals.  2nd  Edition,  with  Preface  by  Drs.  Osier 
and  Packard In  Preparation. 

BRUCE:     Lectures  on  Tuberculosis  to  Nurses.    Based  on 
a   course   delivered   to   the   Queen  Victoria   Jubilee   Nurses. 
By  Olliver  Bruce,  m.r.c.s.,  l.r.c.p,.  Joint  Tuberculosis  OflS.cer, 
County  of  Essex. 
12mo,  Cloth,  124  Pages,  Illustrated $1.00  net. 

BRUNTON:     Therapeutics    of   the    Circulation.    By   Sir 
Lauder     Brunton,     m.d.,     d.sc,    ll.d.    Edin.,    ll.d.    Aberd., 
f.r.c.p.,   f.r.s.     Consulting  Physician  to   St.   Bartholomew's 
Hospital.     Second  Edition,  Entirely  Revised. 
Cloth,  xxiv-|-536  Pages,  110  Illustrations $2.50  nd. 

BULKLEY:     Cancer:    Its  Cause  and  Treatment,  Volume 
I.     By  L.  Duncan  Bulkley. 
8vo,  Cloth.  224  Pages $1.50  net. 

BULEXlEY  :  Cancer  :  Its  Cause  and  Treatment,  Volume  n. 
By  L.  Duncan  Bulkley.    Svo,  Cloth,  272  Pages $1.50  net. 


EOEBEB'S  MEDICAL  MONOGBAPHS  3 

BULKLEY:  Compendium  of  Diseases  of  the  Skin.  Based 
on  an  analysis  of  thirty  thousand  consecutive  cases.  With 
a  Therapeutic  Formulary,  by  L.  Duncan  Bulkley,  a.m., 
M.D.  Physician  to  the  New  York  Skin  and  Cancer  Hospital; 
Consulting  Physician  to  the  New  York  Hospital. 
8vo,  Cloth,  xviii-f  286  Pages $2.00  net. 

BULKLEY:     Diet  and  Hygiene  in  Diseases  of  the  Skin. 
By  L.  Duncan  Bulkley. 
Svo,  Cloth,  xvi-}-194  Pages $2.00  net. 

BULKLEY:  The  Influence  of  the  Menstrual  Function 
on  Certain  Diseases  of  the  Skin.  By  L.  Duncan  Bulkley. 
12mo,  Cloth,  108  Pages $1.00  net. 

BULKLEY:  Principles  and  Application  of  Local  Treat- 
ment IN  Diseases  of  the  Skin.  By  L.  Duncan  Bulkley. 
12mo,  Cloth,  130  Pages $1.00  net, 

BULKLEY:     The  Relations  of  Diseases  of  the  Skin  to 
Internal  Disorders  :  With  Observations  on  Diet,  Hygiene 
AND  General  Therapeutics.     By  L.  Duncan  Bulkley. 
12mo,  Cloth,  175  Pages $1.50  net. 

CARREL  AND  DEHELLY:  The  Treatment  op  Infected 
Wounds.  By  A.  Carrel  and  G.  Dehelly.  Authorized  Transla- 
tion from  the  French  by  Herbert  Child,  m.d..  Formerly  Sur- 
geon, French  Red  Cross,  Capt.  r.a.m.c.  (Ty.),  with  an 
Introduction  by  Sir  Anthony  A.  Bowlby,  f.r.c.s..  Temporary 
Surgeon  General,  Army  Medical  Service. 
12mo,  Cloth,  250  Pages,  97  lUustrations $2.00  net. 

CAUTLEY:     The  Diseases  of  Infants  and  Children.    By 
Edmund  Cautley,  m.d.  Cantab.,  f.r.c.p.  Lond.    Senior  Physi- 
cian to  the  Belgrave  Hospital  for  Children,  etc. 
Large  Svo,  Cloth,  1042  Pages $7.00  net, 

CLARKE :    Problems  in  the  Accommodation  and  Refraction 
OF  the  Eye,  a  Brief  Review  of  the  Work  of  Bonders, 
AND  the  Progress  Made  During  the  Last  Fifty  Years.  By 
Ernest   Clarke,   m.d.,   b.s.,   f.r.c.s. 
Svo,  Boards,  110  Pages $1.00  net. 

COOKE:     The  Position  of  the  X-Rays  in  the  Diagnosis 
AND  Prognosis  of  Pulmonary  Tuberculosis.     By  W.  E. 
Cooke,  M.B.,  M.R.C.P.E.,  D.p.H.   (Lond.). 
8vo,  Cloth,  Illustrated $1.50  net. 

COOPER:     Pathological    Inebriety.     Its    Causation    and 
Treatment.     By  J.  W.  Astley  Cooper.     Medical  Superin- 
tendent and  Licensee  of  Ghyllwood  Sanatorium.    With  Intro- 
duction by  Sir  David  Ferrier,  m.d.,  f.r.s. 
12mo,  Cloth,  xvi+151  Pages $1.50  net. 


4  EOEBEB'S  MEDICAL  MONOGRAPHS 

COOPER:     The   Skxual   Disabilities   of   Man,   and   Their 
Treatment.    By  Arthur  Cooper.    Consulting  Surgeon  to  the 
Westminster  General  Dispensary,  London. 
3rd  Edition,  12mo,  Cloth,  viii+227  Pages $2.50  net. 

COEBETT-SMITH  :  The  Problem  of  the  Nations.  A  Study 
in  the  Causes,  Symptoms  and  Effects  of  Sexual  Disease,  and 
the  Education  of  the  Individual  Therein.  By  A.  Corbett- 
Smith,  Editor  of  The  Journal  of  State  Medicine;  Lec- 
turer in  Public  Health  Law  at  the  Royal  Institute  of  Public 
Health.    Large  8vo,  Cloth,  xii+107  Pages $1.00  net, 

CORNET :    Acute  General  Miliary  Tuberculosis.    By  Prof. 
Dr.  G.  Cornet,  Berlin.     Transl.  by  F.  S.  Tinker,  B.A.,  m.b. 
8vo,  Cloth,  viii-1-107  Pages $1.50  net. 

CEOOKSHANK:     Flatulence  and  Shock.    By  F.  G.  Crook- 
shank,  M.D.  Lend.,  m.r.c.p.    Physician  (Out  Patients)  Hamp- 
stead  General  and  N.  W.  Lend.  Hospital. 
8vo,  Cloth,  iv-1-47  Pages $1.00  net. 

DAVIDSON:     Localization    by    X-Rays    and    Stereoscopy. 
By  Sir  James  Mackenzie  Davidson,  m.b.,  cm.  Aberd.     Con- 
sulting  Medical   Officer,   Roentgen  Ray   Department,   Royal 
London  Ophthalmic  Hospital. 
8vo,  Cloth,  72  pp.,  Plates  and  58  Stereo.  Figs $3.00  net. 

DAWSON:     The  Causation  of  Sex  in  Man.    By  E.  Rumley 
Dawson,  l.r.c.p.  Lend.,  m.r.c.s.  England. 
8vo,  Cloth,  240  Pages,  with  21  Illustrations $3.00  net. 

DELORME:  War  Surgery.  By  Edmond  Delorme,  General 
Medical  Inspector  of  the  French  Army.  Translated  by  D. 
De  Meric,  Surgeon  to  In-Patients,  French  Hospital,  London. 
12mo,  Cloth,  Illustrated,  248  Pages $1.50  net, 

EDRIDGE-GREEN:     The  Hunterian  Lectures  on  Colour- 
Vision  and  Colour  Blindness.    Delivered  before  the  Royal 
College  of  Surgeons  of  England  on  February  1st  and  3rd, 
1911.     By  Professor  P.  W.  Edridge-Green,  m.d.,  f.r.c.s. 
8vo,  Cloth,  x-l-76  Pages $1.50  net. 

EHRLICH:  Experimental  Researches  on  Specific  Thera- 
peutics. By  Prof.  Paul  Ehrlich,  m.d.,  d.sc.  Oxon.  The 
Harben  Lectures  for  1907  of  Royal  Institute  of  Public  Health. 
16mo,  Cloth,  x+95  Pages $1.00  net. 

EINHORN:      Lectures    on    Dietetics.     By    Max    Einhorn, 
Professor  of  Medicine  at  N.  Y.  Post-Graduate  Med.  School 
and  Hospital,  Visit.  Phys.  German  Hospital,  N.  Y. 
12mo,  Cloth,  xviH-156  Pages $1.25  net. 

ELLIOT :  Glaucoma.  By  Col.  Robert  Henry  Elliot,  m.d.,  f.r.c.s. 
8vO;  Cloth,  60  Pages,  with  23  Illustrations $1.50  net. 


HOEBEE'S  MEDICAL  M0N0GBAPH8  5 

ELLIOT:  Sclero-Corneal  Trephining  in  the  Operative 
Treatment  of  Glaucoma.  By  Eobert  Henry  Elliot,  m.d., 
B.s.  Lond.,  D.sc.  Edin.,  f.r.c.s.  Eng.  Lieut.  Colonel  i.M.S. 
2d  Ed.     8vo,  Cloth,  135  Pages,  33  Illus $3.00  net. 

EMEEY:  Immunity  and  Specific  Therapy.  By  Wm.  D'Este 
Emery,  m.d.,  b.sc.  Lond.  Clinical  Pathologist  to  King's 
College  Hospital  and  Pathologist  to  the  Children's  Hospital. 
8vo,  Cloth,  448  Pages,  with  2  Illustrations $3.50  net. 

ADOPTED  BY  THE  U.  S.  ARMY. 

FAILLA,  JANEWAY  AND  BAKEINGEK:  Eadium  Therapy 
in  Cancer  at  the  Memokiax,  Hospital.  (See  Janeway,  Bar- 
ringer  and  Eailla.) 

FISHBEEG:     The  Internal  Secretions.     (See  Gley.) 

FEIESNEE  AND  BEAUN:  Cerebellar  Abscess;  It3  Eti- 
ology, Pathology,  Diagnosis  and  Treatment.  By  Isidore 
Friesner,  m.d.,  f.a.c.s.,  Adjunct  Professor  of  Otology  and 
Assistant  Aural  Surgeon,  Manhattan  Eye,  Ear  and  Throat 
Hospital  and  Post-Graduate  Medical  School,  and  Alfred 
Braun,  m.d.,  f.a.c.s.,  Assistant  Aural  Surgeon,  Manhattan 
Eye,  Ear  and  Throat  Hospital,  Adjunct  Professor  of 
Laryngology,  New  York  Polyclinic  Hospital  and  Medical 
School  and  Adjunct  Otologist,  Mt.  Sinai  Hospital. 
8vo,  Cloth,  186  Pages,  10  Plates,  16  Illus $2.50  net. 

GEESTEE:     Eecollections  of  a  New  York  Surgeon.     By 
Arpad  G.  Gerster,  m.d. 
8vo,  Cloth,  about  375  Pages,  Illustrated $3.50  net. 

GHON:     The    Primary   Lung   Focus   of   Tuberculosis   in 
Children.     By  Anton   Ghon,  m.d.,  English   Translation  by 
D.  Barty  King,  m.a.,  m.d.  Edin.,  m.r.c.p. 
Large  8vo,  Cloth,  196  pp.,  72  lUus.,  2  Plates $3.75  net. 

GILES:     Anatomy  and  Physiology  of  the  Female  Genera- 
tive Organs  and  of  Pregnancy.    By  Arthur  E.  Giles,  m.d., 
b.sc.  Lond.,  m.r.c.p.  Lond.;  f.r.c.s.  Ed.    Gynecologist  to  the 
Prince  of  Wales  General  Hospital. 
Large  8vo,  24  Pages,  with  Mannikin $1.50  net. 

GLEY:    The  Internal  Secretions.    By  E.  Gley,  m.d.    Mem- 
ber  of    the   Academy   of    Medicine   of   Paris,   Professor   of 
Physiology  in  the  College  of  Prance,  etc.    Authorized  Trans- 
lation, Translated  and  Edited  by  Maurice  Fishberg,  m.d. 
8vo,  Cloth,  241  Pages $2.00  net. 

GOULSTON:  Cane  Sugar  and  Heart  Disease.  By  Arthur 
Goulston,  m.a.,  m.d.  Cantab.  Hunterian  Society's  Medallist, 
1912.    8vo,  Cloth,  107  Pages $2.00  net. 


6  HOEBEB'S  MEDICAL  MONOGRAPHS 

GEEEFF:  Guide  to  the  Microscopic  Examination  op  the 
Eye.  By  Professor  E.  Greeff.  Director  of  the  University 
Ophthalmic  Clinique  in  the  Eoyal  Charity  Hospital,  Berlin. 
With  the  co-operation  of  Professor  Stock  and  Professor 
Wintersteiner.  Translated  from  the  third  German  Edition 
by  Hugh  Walker,  m.d.,  m.b.,  cm. 
Large  8vo,  Cloth,  86  Pages,  Illustrated $2.00  net. 

HAEEIS:     Lectures   on   Medical  Electricity  to   Nurses. 
An  Illustrated  Manual  by  J.  Delpratt  Harris,  m.d.,  m.r.c.s. 
12mo,  Cloth,  88  Pages,  Illustrated $1.00  net. 

HELLMAN:  Amnesia  and  Analgesia  in  Parturition — 
Twilight  Sleep.  By  Alfred  M.  HeUman,  b.a.,  m.d.,  p.a.c.s. 
8vo,  Cloth,  with  Charts,  200  Pages $1.50  net. 

HEWATT:     The    Examination    of    the    Urine,    and    Other 
Clinical  Side  Eoom  Methods.     By  Andrew  Fergus  Hewatt, 
M.B.,  ch.b.,  m.r.c.p.  Edin. 
16mo,  5th  Edition,  Numerous  Dlustrations $1.00  net. 

HOFMANN-GAESON :  Eemedial  Gymnastics  for  Heart 
Aefections.  Used  at  Bad-Nauheim.  Being  a  Translation 
of  ''Die  Gymnastik  der  Herzleidenden "  von  Dr.  Med.  Julius 
Hofmann  und  Dr.  Med.  Ludwig  Pohlman.  Berlin  and  Bad- 
Nauheim.  By  John  George  Garson,  m.d.  Edin.,  etc.  Physi- 
cian to  the  Sanatoria  and  Bad-Nauheim,  Eversley,  Hants. 
Large  8vo,  Cloth,  144  Pages,  51  FuU-page  IDus $2.00  net. 

HOWAED:     The  Therapeutic  Value  op  the  Potato.     By 
Heaton  C.  Howard,  l.r.c.p.  Lond.,  m.r.c.s.  Eng. 
8yo,   Paper,   vi-)-31   Pages,   Illustrated 50c 

JANEWAY,  BAEEINGEE  AND  PAILA:  Eadium  Therapy 
IN  Cancer  at  the  Memorial  Hospital,  Eeport  of  1915-1916. 
By  Henry  H.  Janeway,  m.d.,  with  the  Discussion  of  the 
Treatment  of  Cancer  of  the  Prostate  and  Bladder  by  Ben- 
jamin S.  Barringer,  M.D.,  and  an  Introduction  upon  the 
Physics  of  Eadium  by  G.  Failla. 
8vo,  Cloth,  about  225  Pages In  Press. 

JELLETT:  A  Short  Practice  op  Midwifery  for  Nurses. 
Embodying  the  treatment  adopted  in  the  Eotunda  Hospital, 
Dublin.  By  Henry  Jellett,  b.a.,  m.d.  (Dublin  University), 
F.R.c.p.i.,  Master  Eotunda  Hospital.  With  Six  Plates  and 
169  Illustrations  in  the  Text,  also  an  Appendix,  a  Glossary 
of  Medical  Terms,  and  the  Eegulations  of  the  Central  Mid- 
wives  Board. 
12mo,  Cloth,  xvi-|-508  Pages $2.50  net. 


HOEBEB'S  MEDICAL  MONOGBAPHS  7 

JONES:     Notes  on  Military  Orthopedics.    By  Col.  Eobert 
Jones,  C.B.,  Inspector  of  Military  Orthopaedics,  Army  Med- 
ical Service. 
8vo,  Cloth,  132  Pages,  95  lUustrations $1.50  net. 

KENWOOD :     Public  Health  Laboeatory  Woek.    By  Henry 

E.  Kenwood,  m.b.,  f.r.s.  Edin.,  p.p.h.,  f.c.s.,  Chadwick 
Prof,  of  Hygiene  and  Public  Health,  University  of  London. 
6th  Edition,  8vo,  Cloth,  418  Pages,  Hlustrated $4.00  net. 

EIEELEY:     What  Every  Mother  Should  Know  About  Hee 
Infants  and  Young  Children.    By  Charles  Gilmore  Kerley, 
M.D.     Professor  of  Diseases  of   Children,  N.  Y.  Polyclinic 
Medical    School    and    Hospital. 
8vo,  Paper,  107  Pages 3oc  net. 

KETTLE:     The  Pathology  of  Tumors.     By  E.  H.  Kettle, 
M.D.,  B.S.,  Assistant  Pathologist,  St.  Mary^s  Hospital,  and 
Assistant  Lecturer  on  Pathology,  St.  Mary^s  Hospital. 
8vo,  Cloth,  242  Pages,  126  lUustrations $3.00  net. 

LEWEES:  A  Practical  Textbook  of  thb  Diseases  of 
Women.  By  Arthur  H.  N.  Lewers,  m.d.  Lond.  Senior 
Obstetric  Physician,  London  Hospital. 

With  258  Illustrations,  13  Colored  Plates,  5  Plates  in  Black 
and  White.   7th  Ed.,  8vo,  Cloth,  sii+540  Pages $4.00  net. 

LEWIS :     Clinical  Disorders  of  the  Heart  Beat.    A  Hand- 
book for  Practitioners  and  Students.    By  Thomas  Lewis,  m.d., 
D.sc,  F.R.c.p.     Assistant  Physician  and  Lecturer  in  Cardiac 
Pathology,  University  College  Hospital  Medical  School. 
3rd  Ed.,  8vo,  Cloth,  116  Pages,  54  Illustrations.  .$2.00  net. 

LEWIS:     Lectures  on  the  Heart.     Comprising  the  Herter 
Lectures   (Baltimore),  a  Harvey  Lecture   (New  York),  and 
an  Address  to  the  Faculty  of  Medicine  at  McGill  University 
(Montreal).     By  Thomas  Lewis. 
124  Pages,  vdth  83  Illustrations $2.00  net. 

LEWIS :  Clinical  Electrocardiography.  By  Thomas  Lewis. 
8vo,  Cloth,   120   Pages,  with  Charts $2.00  net. 

LEWIS :  The  Mechanism  of  the  Heart  Beat.  With  Special 
Eeference  to  Its  Clinical  Pathology.  By  Thomas  Lewis. 
Large  8vo,  Cloth,  295  Pages,  227  lUus $7.00  net, 

McCLUEE:    A  Handbook  of  Fevers.     By  J.  Campbell  Mc- 
Clure,     M.D,,     Glasgow.       Physician     to     Out-Patients,     The- 
French    Hospital,    and    Physician    to    the    Margaret    Street 
Hospital  for  Consumption  and  Diseases  of  the  Chest,  London. 
8vo,  Cloth,  470  Pages,  with  Charts $3.50  net. 


8  EOEBEE'S  MEDICAL  MONOGBAPES 

McCRUDDEN:    The  Chemistry,  Physiology  and  Pathology 
OP  Uric  Acid,  and  the  Physiologically  Important  Pubin 
Bodies.    With  a  Discussion  of  the  Metabolism  in  Gout.     By 
Francis   H.   McCrudden. 
12mo,  Paper,  318  Pages $2.00  net. 

McKISACK:    Systematic   Case  Taking.     A  Practical  Guide 
to  the   Examination  and  Recording  of  Medical  Cases.     By 
Henry  Lawrence  McKisack,  m.d.,  m.r.c.p.  Lond. 
12mo,  Cloth,  166  Pages $1.50  net. 

MACKENZIE:     Symptoms  and  Their  Interpretations.    By 
James  Mackenzie,  m.d.,  ll.d.  Aber.  and  Edin. 
8vo,  Cloth,  Illustrated,  xxii-f304  Pages $3.00  net. 

MACMICHAEL:  The  Gold-Headed  Cane.  By  William  Mac- 
michael.  Reprinted  from  the  2nd  Edition.  With  a  Preface 
by  Sir  William  Osier  and  an  Introduction  by  Dr.  Francis  E. 
Packard.  Printed  from  large  Scotch  type  on  a  special  heavy- 
weight paper,  5^  by  7%  inches,  bound  in  blue  Italian  hand- 
made paper,  with  parchment  back,  gilt  top,  square  back, 
and  gold  stamping  on  back  and  side $3.00  net. 

MAGIDL:     Notes  on  Galvanism  and  Faradism.    By  E.  M. 
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HOEBEB'S  MEDICAL  MONOGBAPHS  9 

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10  EOEBEB'S  MEDICAL  MONOGBAPES  ' 

SCHMITT:  Studies  in  the  Anatomy  and  Surgeky  of  the 
Nose  and  Ear.  By  A.  Emil  Sclimitt,  m.d.,  Past  Chief  Med- 
ical and  Sanitary  Officer,  Nile  Reservoir  Works,  Assuan, 
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BMITH:    Some  Common  Remedies,  and  Their  Use  in  Prac- 
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SQTJIER  and  BUGBEE:  ?^Ianual  of  Cystoscopy.  By  J. 
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STEPHENSON:     Eye-Strain   in   Eveby-day  Practice.     By 
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EOEBEB'8  MEDICAL  MONOGBAPHS  11 

STEPHENSON:     A  Review  of  Hoemone  Theeapy.     1913. 

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Bound   and   interleaved   edition   of   the   famous   **  Hormone 
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SWIETOCHOWSKI:      Mechano-Theeapeutics    in    Geneeal 
Peactice.    By  G.  de  Swietochowski,  m.d.,  m.e.c.s.    Fellow  of 
the  Eoyal  Society  of  Medicine;  Clinical  Assistant,  Electrical 
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TOUSEY:  Eoentgenogeaphic  Diagnosis  of  Dental  Infec- 
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TEUESDELL:  Birth  Feactures  and  Epiphyseal  Disloca- 
tions. By  Edward  D.  Truesdell,  m.d.,  Assistant  Attending 
Surgeon  and  Roentgenologist,  Lying-in  Hospital,  Associate 
Surgeon,  St.  Mary's  Eree  Hospital  for  Children,  New  York. 
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TURNER  and  PORTER:  The  Skiagraphy  of  the  Acces- 
soEY  Nasal  Sinuses.  By  A.  Logan  Turner,  M.D.,  f.e.c.s.b., 
f.e.s.e.  Surgeon  to  the  Ear  and  Throat  Department,  the 
Royal  Infirmary,  Edinburgh,  and  W.  G.  Porter,  M.B.,  B.SC, 
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VON    RUCK    and    von    RUCK:     Studies    in    Immunization 
against    Tuberculosis.      By    Karl    von    Ruck,    m.d.,    and 
Silvio  von  Ruck,  m.d. 
8vo,  Cloth,  svi+439  Pages $4.00  7iet. 

WANKLYN:  How  to  Diagnose  Smallpox.  A  Guide  for 
General  Practitioners,  Post-Graduate  Students,  and  Others. 
By  W.  McC.  Wanklyn,  b.a.  Cantab.,  M.E.C.S.,  L.E.C.P.,  d.p.h. 
8vo,  Cloth,  102  Pages,  lUustrated $1.50  net. 

WATSON :  Gonorehcea  and  Its  Complications  in  the  Male 
AND  Female.  By  David  Watson,  m.b.,  cm.,  Surgeon,  Glasgow 
Lock  Hospital  Dispensary,  Surgeon  for  Venereal  Diseases, 
Glasgow  Royal  Infirmary,  etc.,  etc. 

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WHITE :     The  Pathology  of  Geowth.  Tumours.  By  Charles 
Powell    White,    m.c,    f.e.c.s.      Director,    Pilkington    Cancer 
Research  Fund,  Pathologist  Christie  Hospital,  Special  Lec- 
turer in  Pathology,  University  of  Manchester. 
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12  HOEBEB'S  MEDICAL  M0N0GBAPH8 

WHITE:  Occupational  Affections  op  the  Skin,  A  brief 
account  of  the  trade  Processes  and  Agents  "which  give  rise 
to  them.  By  P.  Prosser  White,  m.d.  Ed.,  m.r.c.s.  Lond.  Life 
Vice-President,  Senior  Physician  and  Dermatologist,  Eoyal 
Albert  Edward  Infirmary. 
8vo,  Cloth,  165  Pages $2.00  net. 

WICKHAM  and  DEGRAIS:  Eadium.  As  employed  in  the 
treatment  of  Cancer,  Angiomata,  Keloids,  Local  Tuberculosis 
and  other  affections.  By  Louis  Wickham,  m.v.o.  M^decin 
de  St.  Lazare;  Ex-Chef  de  Clinique  h  L'HSpital  St. 
Louis,  and  Paul  Degrais,  Ex-Chef  de  Laboratoire  h.  L*H6pitaJ 
St.  Louis. 
8vo,  Cloth,  53  niustrations,  viii-f-111  Pages $1.25  net. 

WEENCH :     The  Healthy  Maerl&ge.    A  Medical  and  Psycho- 
logical Guide  for  Wives.    By  G.  T.  Wrench,  m.d.,  b.s.  Lond., 
Past  Assistant  Master  of  the  Rotunda  Hospital,  Dublin. 
2nd  Edition,  8vo,  Cloth,  viii-fSOO  Pages $1.50  net. 

WEIGHT:    The  Unexpurgated  Case  against  Woman  Suf- 
frage.    By  Sir  Almroth  E.  Wright,  m.d.,  f.r.s. 
8vo,  Cloth,  xii4-188  Pages $1.00  net. 

WEIGHT:  On  Pharmacotherapy  and  Preventivb  Inocu- 
lation; Applied  to  Pneumonia  in  the  African  Native,  with 
a  Discourse  on  the  Logical  Methods  Which  Ought  to  Be 
Employed  ia  the  Evaluation  of  Therapeutic  Agents.  By 
Sir  Almroth  E.  Wright,  M.D.,  f.e.S. 
8vo,  Cloth,  124  Pages $2.00  net. 

YOUNG:  The  INIentally  Defective  Child.  By  Meredith 
Young,  M.D.,  D.P.H.,  D.s.sc,  Chief  School  Medical  Officer, 
Cheshire  Education  Committee;  Lecturer  in  School  Hygiene, 
Victoria  University  of  Manchester;  Certifying  Medical  Offi- 
cer to  Local  Authority  (Mental  Deficiency  Act),  Co.  Cheshire. 
12mo,  Cloth,  xi+140  Pages.     Illustrated $1.50  net. 

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